The Pharmacy Benefit Audit Playbook
Audits Every Payer Should Be Considering and How PSG Can Help Pharmacy benefit audits should go beyond checking a compliance box. When approached strategically,…
Custom Audits
SOLUTIONS
Custom Audits
No two pharmacy programs are alike, and sometimes a standard audit scope does not align with the specific challenge you need to solve. Whether it’s a targeted review of a single contract provision, a deep dive into a specialized arrangement like a specialty drug carve-out, or an evaluation of non-standard components unique to your program, custom audits give you the flexibility to direct PSG’s expertise exactly where it matters most. Custom audits are targeted audits designed for client-specific needs, built around your organization’s priorities, PBM contract structure, and areas of greatest risk or opportunity.
Uncover Hidden Value. Protect Every Dollar
Ensure Contract Compliance
Custom audits verify that even the most nuanced or non-standard provisions in your PBM contract are being followed, closing gaps that standard audit scopes may not cover.
Recover Dollars Left on the Table
Specialized arrangements and non-standard contract components are often where hidden discrepancies live. PSG custom audits consistently identify errors in areas that might otherwise go unexamined.
Strengthen Fiduciary Responsibility
Custom audits demonstrate prudent oversight in areas of unique risk, reinforcing your commitment to protecting plan assets and member interests.
Turn Audits Into Strategy
Custom audits go beyond compliance to provide targeted intelligence on the areas that matter most to your organization, enabling more focused decision-making and stronger vendor accountability.
PSG’s Custom Audits
Custom Audit
A Custom Audit is a targeted, client-specific engagement designed to address areas of concern that fall outside the scope of PSG’s standard audit categories. PSG works with your organization to define the audit’s scope, focus, and deliverables based on your unique PBM contract terms, program structure, and strategic priorities.
Custom audits can address a wide range of non-standard components, including specialty drug carve-out arrangements, clinical program configurations, ROI guarantee validation, delegated services such as prior authorization processes, alternative pricing model validation, Prescription Drug Event (PDE) audits for Medicare plans, or any other area where independent verification would add value.
PSG’s approach begins with understanding the specific question you need answered, then builds the methodology, data requirements, and reporting structure around that question. Claims data is loaded into PSG’s proprietary tools, and the audit is executed with the same rigor and independence applied to any standard engagement.
Common Triggers for Conducting This Audit:
- A specific contract provision or operational concern that does not fit neatly into a standard audit category
- Specialized arrangements such as specialty drug carve-outs, unique clinical program configurations, or delegated PBM services that require independent verification
- Regulatory or compliance requirements unique to your market segment (e.g., PDE audits for Medicare Advantage plans)
- Concerns about claims integrity, including AWP validation, duplicate claims, obsolete NDCs, or brand/generic classification
- Need to validate non-standard pricing models, fee structures, or reconciliation methodologies
- Follow-up audit to investigate specific findings from a prior comprehensive or standard audit
Why choose PSG?
Independence You Can Trust
Our audit findings are free from PBM affiliations or industry bias. When we evaluate your specialized arrangements, non-standard contract provisions, or unique program components, the results are fact based, not influenced by a vendor relationship.
Unmatched Audit Expertise
Our auditors combine pharmacy benefit experience with technical expertise in a way few organizations can match. Using proprietary auditing tools and a contract-true methodology, we rebuild your program logic from the ground up using exact contract definitions to remove ambiguity. This dual fluency allows us to interrogate large, complex data sets and identify issues that standard reporting would miss, even in non-standard or first-of-their-kind audit engagements.
Breadth Across Every Market and Size
Our capabilities span every major market segment (commercial/exchange, Medicare, Medicaid, and beyond). Whether you cover 500 lives or 5 million, we have the experience and methodology to scale accordingly, bringing cross-market perspective to every engagement.
Flexible, Tailored Approach
This is where PSG’s flexibility is most evident. Custom audits are built entirely around your organization’s goals. Choose a single targeted review or combine services to align with your strategic priorities. The final scope, methodology, and deliverables are defined collaboratively with your team, ensuring the audit addresses the exact questions you need answered.