Recovery Demand Process
- 1Document findings: Prepare a detailed audit report with specific claim-level findings
- 2Calculate recovery: Calculate the total recovery amount for each finding category
- 3Present to PBM: Present findings to the PBM account team with a recovery demand
- 4Negotiate: PBMs typically negotiate — be prepared to defend your methodology
- 5Settle: Agree on a recovery amount and payment timeline
- 6Document: Document the settlement and use findings to improve contract terms
Contract Improvement
Audit findings should be used to negotiate improved contract terms at renewal. If the audit finds that the PBM is retaining rebates that should be passed to the employer, negotiate a stronger rebate pass-through guarantee. If the audit finds spread pricing, negotiate a spread-free contract. Audit findings are the most powerful leverage for contract renegotiation.
Recurring Findings
Watch Out
Recurring audit findings — the same issues found in multiple consecutive audits — indicate systemic contract violations, not one-time errors. A PBM that repeatedly processes claims above contracted rates or retains rebates that should be passed to the employer is not complying with the contract. Recurring findings are grounds for contract termination and PBM replacement.