01
Hidden Fees & Spread Pricing
Administrative fees, pricing spreads, claim markups, and undisclosed economics can materially increase pharmacy benefit costs.
Pharmacy Benefit Manager
Forensic Audit
Where Oversight Meets Accountability.
Pharmacy Benefit Manager Forensic Audit
Recover pharmacy spend.
Increase transparency.
Hold PBMs accountable.
A forensic PBM audit helps employers, plan sponsors, funds, trusts, healthcare organizations, and independent pharmacies uncover hidden costs, validate contract performance, recover missed value, and strengthen oversight of pharmacy benefit programs.
The PBM Problem
Organizations often overpay because PBM performance is difficult to see.
PBM contracts are often intentionally complex, and plan sponsors rarely receive enough actionable information to confirm that discounts, rebates, dispensing fees, guarantees, and utilization patterns align with the contract.
02
Missed Rebates
Manufacturer rebate arrangements are often difficult to verify without reviewing contract terms, reconciliation data, and payment reports.
03
Performance Failures
PBMs may fail to meet contractual guarantees for discounts, dispensing fees, rebates, specialty claims, or other financial terms.
04
Limited Oversight
Without monthly reporting and independent review, employers and pharmacies often lack leverage to challenge PBM performance.
10–20%
Potential savings identified across pharmacy spend when contract and claims issues are uncovered.
12–24
Months of historical PBM claims and contract performance data reviewed in the initial analysis.
70/30
Client-focused recovery model where the client retains the majority of identified recoveries.
0 PBM
CGM does not sell PBM services. The audit is designed to evaluate the current PBM relationship.
Executive-Level Visibility
Designed for CFOs, benefits leaders, trustees, and pharmacy operators.
The PBM Forensic Audit converts dense contract terms, rebate files, claims data, and utilization trends into a clear executive view of financial leakage, contractual variance, and recovery opportunity.
PBM Forensic Audit Solution
A comprehensive review of PBM contracts, claims, rebates, and utilization.
The audit identifies overpayments, missed rebates, contract inefficiencies, guarantee failures, and pharmacy spend drivers that are often invisible without a focused forensic review.
What We Review
Contract terms, claims data, pricing, rebates, and guarantees.
- PBM contracts
- Contract amendments
- Pricing exhibits
- Claims data
- Discount guarantees
- Dispensing fees
- Rebate reports
- MAC pricing
- Specialty pricing
- Admin fees
- Utilization trends
- Channel mix
What We Identify
Recoveries, compliance gaps, and opportunities to improve value.
- Overpayments
- Missed rebates
- Spread pricing
- Guarantee failures
- Improper MAC pricing
- Specialty cost issues
- Contract gaps
- Fee leakage
- Claims discrepancies
- Utilization drivers
- Plan inefficiencies
- Recovery opportunities
Interactive Audit View
Explore what the PBM audit evaluates.
Claims & Pricing Validation
Review claims transaction data, AWP values, MAC pricing, dispensing fees, specialty claims, administrative fees, and member cost share to identify overpayments and pricing issues.
Rebate Performance
Evaluate rebate guarantee terms, manufacturer rebate reports, reconciliation files, and whether the PBM passed through the value required under the agreement.
Contract Compliance
Compare PBM performance against contract definitions, amendments, pricing exhibits, guarantee schedules, carve-outs, and audit rights.
Monthly Oversight
Continue tracking PBM performance against guarantees, utilization trends, top drugs, pharmacy channels, specialty spend, and emerging recovery opportunities.
Audit Process
Built to minimize client burden while maximizing recovery visibility.
The process is designed so your team provides the PBM contract and directs the PBM to release claims data. From there, the audit team performs the review, quantifies findings, and supports recovery and ongoing monitoring.
Send PBM Contract
Provide the current PBM contract, amendments, pricing exhibits, rebate terms, and guarantee schedules.
Release Claims Data
Direct the PBM and related vendors to provide claims, rebate, guarantee, invoice, and reconciliation files.
Receive Findings
Review detailed findings identifying recoveries, performance shortfalls, pricing issues, and savings opportunities.
Recover & Monitor
Use the findings to pursue recovery from the PBM and continue monthly monitoring to protect future performance.
Two Audit Paths
Choose the audit path that fits your organization — historical, ongoing, or both.
The PBM engagement can be structured as a historical forensic audit, ongoing monthly monitoring, or a combined engagement. Clients can choose one path, the other, or both based on current priorities, PBM contract restrictions, timing, and budget preferences.
Audit One
Historical PBM Forensic Audit
We review the prior 12 to 24 months of PBM contracts, claims, rebate reports, pricing guarantees, dispensing fees, invoices, specialty claims, and performance calculations to identify recoveries, overpayments, pricing discrepancies, and contract failures.
- Retrospective claims and pricing review
- Discount, rebate, and guarantee validation
- Recovery opportunity quantification
- Executive-ready findings and recommendations
Audit Two
Ongoing Monthly PBM Monitoring
This audit can be selected independently or paired with a historical review. Monthly monitoring helps your organization avoid dependence on PBM self-reporting and identify missed performance, emerging cost trends, and contract variances before they become larger losses.
- Monthly report card and trend reporting
- Contract guarantee performance monitoring
- Top drugs, pharmacies, patients, and utilization insights
- Continuous PBM accountability and oversight
Measurable Financial Impact
Recover hidden pharmacy spend and improve long-term PBM oversight.
Organizations can uncover 10%–20% or more in pharmacy spend opportunity through retrospective analysis, pricing validation, rebate reconciliation, and improved contract oversight.
Fiduciary Oversight
PBM accountability is becoming a board-level and fiduciary issue.
Employers sponsoring self-insured health plans must act prudently and solely in the interest of plan participants. PBM oversight is increasingly central to that responsibility.
Rising Legal Scrutiny
Recent lawsuits against large employers highlight allegations of inadequate PBM oversight, inflated prescription costs, and failure to monitor plan vendors.
Fiduciary Integrity
Employers must ensure plan costs are reasonable, third-party vendors are monitored, and plan assets are managed in participants’ best interests.
Audit Evidence
A forensic PBM audit creates documentation, financial findings, and oversight processes that help demonstrate prudent vendor monitoring.
How The Audit Helps
Detailed cost, contract, compliance, and recovery analysis.
The audit translates complex PBM contract language, claims data, pricing files, and rebate information into clear financial findings and a practical roadmap for recovery and improved governance.
1
Detailed Cost Analysis
Identify inflated pricing, hidden spread margins, claim overpayments, and undisclosed financial leakage.
2
Contract Compliance Review
Evaluate whether the PBM contract and execution align with pricing guarantees, rebate terms, and fiduciary standards.
3
Benchmarking & Comparison
Compare pharmacy performance against contract expectations, market norms, and utilization trends.
4
Recovery & Renegotiation
Use audit findings to pursue recoveries, improve contract terms, and strengthen future PBM oversight.
Monthly Report Monitoring
Ongoing visibility into PBM responsibilities, contract guarantees, and pharmacy spend.
After the initial review, ongoing reporting helps ensure no dollars are left on the table and that PBM performance remains aligned with contractual obligations.
Contract Guarantee Monitoring
Audit PBM performance against contract guarantees for discounts, dispensing fees, rebate pass-throughs, and financial terms.
Drug & Utilization Reporting
Identify top costly and frequently used brand, generic, specialty, and high-cost drugs driving pharmacy spend.
Pharmacy & Member Insights
Gain insight into top pharmacies, top patients, member cost trends, and claim utilization patterns requiring oversight.
Flexible Fee Structure
Contingency where permitted. Flat fee where required.
Some PBM contracts permit contingency-based audits, while others restrict or prohibit them. CGM structures the engagement around the client’s PBM contract terms so the audit can move forward without unnecessary friction.
Initial Revenue Projection
If contingency-based audit fees are not permitted, we first perform an initial analysis to estimate potential revenue recovery, pricing variance, rebate leakage, and overall savings opportunity before the full audit begins.
Contingency-Based Audit
When permitted, recoveries may be structured through a client-focused contingency model where the client retains the majority of identified recovery value and CGM is compensated based on measurable results.
Flat-Fee Audit
When contingency fees are not allowed, CGM can perform the PBM forensic audit under a fixed-fee structure based on the scope, available data, number of plans, and complexity of the PBM arrangement.
Traditional PBM Oversight vs. CGM PBM Forensic Audit
Why passive PBM management leaves money and leverage on the table.
Passive PBM Oversight
CGM PBM Forensic Audit
Relies on PBM self-reporting
Independently validates claims, rebates, and guarantees
Limited visibility into hidden economics
Identifies hidden fees, spreads, and overpayments
Rebate performance often unclear
Reviews rebate terms, payments, and reconciliation data
Contract language is difficult to enforce
Translates contract terms into measurable audit findings
Little evidence of fiduciary monitoring
Creates documentation of prudent oversight and analysis
Missed recoveries may remain undiscovered
Quantifies recovery opportunities and ongoing savings
Support for Independent Pharmacies
Protect margins. Strengthen leverage. Preserve patient trust.
PBM pressure is not limited to employer-sponsored plans. Independent pharmacies can also use PBM audit and monitoring support to identify reimbursement issues, contract discrepancies, PSAO concerns, margin erosion, clawback exposure, and claims that may create compliance risk.
01
Margin Tracking & Reimbursement
Compare reimbursement amounts to acquisition cost, NADAC or other pricing benchmarks, and identify drugs where reimbursement falls below cost.
02
Contract & PSAO Oversight
Review PBM and PSAO performance, identify discrepancies, and determine whether contract economics are quietly reducing pharmacy margin.
03
Clawback & Compliance Protection
Gain better visibility into high-risk claims, PBM red flags, audit exposure, and reimbursement behavior that may trigger chargebacks or penalties.
04
Negotiation Leverage
Use defensible reporting and claims analysis to challenge unfair reimbursement, support renegotiation, and strengthen PBM-related decision-making.
Begin With Clarity
Ready to uncover what your PBM contract is really costing you?
Start with a PBM Forensic Audit and gain the transparency, documentation, and financial recovery insight needed to hold your PBM accountable.
PBM Accountability Starts Here
The forensic audit methodology utilized in our PBM Audit was developed under the leadership of Dr. Susan A. Hayes, one of the most recognized experts in the United States in pharmacy benefit management auditing, healthcare fraud investigation, and pharmacy claims analytics. Dr. Hayes has more than 40 years of experience in the healthcare consulting and pharmacy benefit management industry and has held leadership roles with Walgreens Healthcare Plus, Systemed Pharmacy, William M. Mercer, Towers Perrin, and Hewitt Associates specializing in pharmacy benefit auditing and PBM procurement. Dr. Hayes currently serves as Director of the Health Informatics Master’s Degree Program at Roosevelt University and is the founder of Pharmacy Investigators and Consultants, a firm specializing in pharmacy benefit consulting, healthcare fraud investigations, and forensic analytics. She has served as an expert witness in numerous PBM litigation matters, including the landmark Rutledge v. PCMA case before the United States Supreme Court concerning state authority to regulate PBM practices.
