When can a PBM conduct an audit without the pharmacy's permission?

A pharmacy benefit manager (PBM) is allowed to conduct an audit within specific timeframes as dictated by regulations. According to Minnesota law, the timeframe for when a PBM can initiate an audit without prior notification or permission from the pharmacy is within the first 5 business days after the claim has been submitted. This rule is enacted to maintain fair practices and ensure that pharmacies are not unduly burdened by an extensive notice period before an audit.

This regulation helps create a balance between allowing PBMs to monitor and audit claims effectively to prevent fraud and ensuring pharmacies have a fair chance to prepare and respond. If the audit occurred beyond this short window, it could impede the pharmacy’s operations and create unnecessary disruptions, so the law places a limit on when an audit can take place without prior permission.

Understanding this timeframe is critical for pharmacy operations, as it informs the policies that pharmacies should have in place regarding their records and procedures for potential audits.