How far back can an audit conducted by a PBM reach?

The correct answer indicates that a pharmacy benefit manager (PBM) can conduct an audit that reaches back two years. This reflects standard practice within the healthcare industry regarding the timeframe for auditing claims and records. The two-year period aligns with the typical statute of limitations for auditing prescription claims, allowing PBMs to verify compliance with both contractual obligations and regulatory requirements uncovered during that timeframe.

This two-year limitation is significant for both pharmacies and patients, as it helps establish a balance between thorough oversight and minimizing the burden on pharmacies in terms of record-keeping and response to audits. Additionally, it promotes financial accuracy within the healthcare system, encouraging pharmacies to maintain proper documentation and compliance with billing practices for a reasonable window of time. Understanding this timeframe is critical for stakeholders in effectively navigating and managing audits and ongoing compliance efforts relevant to pharmacy operations.