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Compliance Considerations for Your Pharmacy Program

12/15/2023 Written by: AP Employee Benefits and Keenan Pharmacy Services

The Pharmacy Benefit Management (PBM) industry, with a market value of $540.32 billion in 2023 and a projected annual growth rate of 8.77% through 2030, reflects the increasing complexity and pivotal role of PBMs in the healthcare industry. This trend has emphasized the importance of comprehensive PBM audits. These audits are a critical part of staying compliant with regulatory standards and identifying ways to reduce costs while healthcare expenses continue to rise.

The Crucial Role of PBM Audits

PBM audits are essential for several reasons:

  1. Regulatory Compliance: As healthcare regulations change, audits are crucial to ensure PBMs adhere to the latest legal standards, thereby mitigating legal and financial risks
  2. Cost Efficiency and Transparency: Audits identify opportunities to reduce costs without compromising service quality, promoting transparency in drug pricing and rebate agreements
  3. Optimized Operations: Audits enable PBMs to streamline processes, enhancing efficiency in claims processing and customer service
  4. Stakeholder Trust: Regular and transparent audits cultivate trust among clients, regulatory bodies, and patients, affirming the PBM's ethical and reliable operations

Compliance Implications for PBMs

Given the stringent regulatory landscape, PBMs face significant compliance challenges. These include:

  • Adhering to Evolving Regulations: Constant changes in healthcare laws require PBMs to stay updated and compliant, necessitating regular audits
  • Ensuring Accurate Drug Pricing: Audits ensure that PBMs charge fair prices, align with industry standards, and adhere to contractual obligations
  • Maintaining Transparency with Rebate Agreements: By auditing rebate agreements, PBMs demonstrate their commitment to transparency and fairness
  • Data Security and Privacy Compliance: With sensitive patient data, PBMs must comply with data protection regulations, a critical component of audit checks

Actionable Steps for HR Compliance Professionals

HR compliance professionals can take proactive measures to address these implications by exercising the following:

  1. Regular Audit Scheduling: Ensure your PBM conducts frequent audits to maintain compliance and operational efficiency
  2. In-depth Contract Review: Thoroughly review PBM contracts for compliance with regulations and cost-effectiveness
  3. Staying Informed on Regulatory Changes: Keep abreast of changes in healthcare laws and regulations that impact PBM operations
  4. Advocating for Transparency: Encourage your PBM to be transparent in their pricing and rebate processes to build trust and ensure compliance

As the PBM market continues to grow, the need for expert audit services becomes increasingly crucial. Strategic consulting and thorough auditing are key to ensuring that PBMs not only comply with current regulations but also operate efficiently and ethically. Your AssuredPartners consultant is a great resource to help your organization strategize and evaluate potential PBM consulting and auditing service providers. Connect with your local team to discuss whether these services are a good fit for your organization.

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