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,…
Pre- and Post-Implementation Audits
SOLUTIONS
Pre- and Post-Implementation Audits
Switching PBMs or onboarding a new pharmacy vendor is one of the most complex and high-stakes transitions in pharmacy benefits. With compressed timelines, complex benefit designs, and massive data migration, even small configuration errors can compound into significant financial exposure and member disruption that may not surface for months. Implementation audits ensure that none of your pharmacy program dollars are being wasted and that plan design parameters are accurate, validating that the contract terms, pricing, and other key components with your newly selected PBM are being adjudicated as contracted. They provide an independent checkpoint at the most vulnerable points in a transition, giving you the confidence that your negotiated contract terms are translating into real-world claims accuracy from day one.
Uncover Hidden Value. Protect Every Dollar
Ensure Contract Compliance
Implementation audits verify that your PBM has accurately configured and is adjudicating claims in accordance with agreed-upon terms from the very start of the relationship, across pricing, plan design, clinical edits, and network access.
Recover Dollars Left on the Table
Configuration errors during implementation can quietly drive overpayments and hide larger plan design errors. PSG audits consistently identify implementation errors before these issues compound over the life of the contract.
Strengthen Fiduciary Responsibility
Implementation audits demonstrate prudent oversight during the most vulnerable period of a PBM transition, when the risk of errors is highest.
Turn Audits Into Strategy
Implementation audits go beyond compliance to reduce transition risk, catch issues early, and set the foundation for a more confident PBM relationship from day one.
PSG’s Pre- and Post-Implementation Audits
Pre-Implementation Audit | Post-Implementation Audit
Pre-Implementation Audit
A Pre-Implementation Audit assesses whether the contract terms, pricing (if configured prior to go-live), and other key components with the newly selected PBM are being adjudicated as expected before the plan effective date. PSG selects a sample claims data set based on select plan designs, then verifies that plan design parameters are being adjudicated in accordance with your established plan design documents. PSG also validates the accuracy of program pricing elements and logic by distribution channel, including retail, mail order, and specialty.
Think of this audit as the first line of defense: it establishes a baseline and identifies critical issues while there is still time to correct them, setting the foundation for the post-implementation audit.
Common Triggers for Conducting This Audit:
- Transition to a new PBM, especially with complex benefit designs or large member populations
- Major changes to formulary, network configuration, or pricing models ahead of a new plan year
- Compressed implementation timelines where configuration accuracy carries elevated risk
- Desire to establish a baseline before go-live that sets the foundation for a post-implementation audit
- Regulatory or fiduciary obligations that require independent validation of plan setup accuracy
Post-Implementation Audit
A Post-Implementation Audit assesses whether the contract terms, pricing, and other key components with the newly selected PBM are being adjudicated as expected in the production environment following go-live. The audit analyzes the first three (3) to six (6) weeks of production data to ensure that pharmacy program dollars are not being wasted and plan design parameters are configured properly resulting in accurate claim adjudication.
PSG loads selected claims into its proprietary contract/plan compliance tool, reviews first three (3) to six (6) weeks of claims against contractual obligations, and validates accuracy of program pricing by distribution channel as well as plan design (member share/copay) parameters. Claims are also reviewed for processing errors, including excluded medications, prior authorization status, quantity limits, and duplicate claims.
Any shortfalls are identified, and PSG produces a final Post-Implementation Audit Report with the source and extent of all pricing variations and plan design errors. If shortfalls are discovered, PSG negotiates financial recovery with the PBM on your behalf. Significant findings are shared as they are discovered during data analysis, prior to the final report. This is particularly important for identifying potential financial performance shortfalls well before year-end reconciliation processes (which typically occur 18 months after go-live), when corrective options may be limited.
Common Triggers for Conducting This Audit:
- Completion of the first three (3) to six (6) weeks following PBM go-live
- Known issues surfaced during pre-implementation testing that require production data validation
- Member complaints or pricing fluctuations observed during the initial months of the new contract
- Desire to validate contractual pricing, plan design, and clinical edit accuracy well before year-end reconciliation
- Contractual audit rights or implementation guarantee provisions that require independent verification
Why choose PSG?
Independence You Can Trust
Our audit findings are free from PBM affiliations or industry bias. When we evaluate your implementation accuracy, pricing configuration, and plan design setup, the results are fact based, not influenced by a vendor relationship.
Unmatched Audit Expertise
Our auditors combine pharmacy benefit experience with deep implementation knowledge in a way few organizations can match. Using our proprietary contract/plan compliance tool, we validate that claims adjudicate according to plan design specifications, including pricing by distribution channel, member cost share, excluded medications, prior authorization status, quantity limits, and duplicate claims. This implementation-specific expertise means we catch discrepancies others overlook.
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
Full-scope and a la carte audit options give you the flexibility to target specific areas of concern, whether that’s a focused pre-implementation pricing review, a comprehensive post-implementation validation, or both. The final scope and focus of each audit is customized based on your organization’s requirements.