Pharmacy Benefit Manager
Forensic Audit
Independent oversight of pharmacy benefit economics.
CG Moneta Consulting conducts forensic PBM audit reviews for employers, plan sponsors, funds, trusts, healthcare organizations, and independent pharmacies seeking to uncover hidden costs, validate contract performance, recover missed financial value, and strengthen oversight of pharmacy benefit programs.
PBM contracts are complex. Oversight should not be optional.
PBM arrangements can contain spread pricing, hidden fees, unrealized rebates, performance guarantee failures, pricing discrepancies, and limited reporting visibility. The audit brings the contract, claims, rebates, utilization data, guarantees, and supporting reports into one disciplined financial review.
Organizations often overpay because PBM performance is difficult to see.
Plan sponsors rarely receive enough actionable information to confirm that discounts, rebates, dispensing fees, pricing guarantees, utilization patterns, and network economics align with the contract. Independent review converts dense PBM data into executive visibility.
Hidden fees and spread pricing
Administrative fees, pricing spreads, claim markups, and undisclosed economics can materially increase pharmacy benefit costs.
Missed rebates
Manufacturer rebate arrangements are difficult to verify without reviewing contract terms, reconciliation data, payment reports, and exclusions.
Performance failures
PBMs may fail to meet contractual guarantees for discounts, dispensing fees, rebates, specialty claims, or other financial terms.
Limited oversight
Without recurring reporting and independent review, employers and pharmacies often lack leverage to challenge PBM performance.
A comprehensive review of PBM contracts, claims, rebates, guarantees, and utilization.
The audit identifies overpayments, missed rebates, contract inefficiencies, guarantee failures, pharmacy spend drivers, and compliance gaps that are often invisible without a focused forensic review.
What we review
Contract terms, claims data, pricing, rebates, utilization, channel mix, and guarantee schedules.
- PBM contracts
- Contract amendments
- Pricing exhibits
- Claims data
- Discount guarantees
- Dispensing fees
- Rebate reports
- MAC pricing
- Specialty pricing
- Administrative fees
- Utilization trends
- Channel mix
What we identify
Recoveries, compliance gaps, pricing failures, and practical measures to strengthen PBM oversight.
- 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
Explore what the PBM audit evaluates.
Claims and 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 issues.
Historical review, ongoing monitoring, 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 or both based on current priorities, PBM contract restrictions, timing, and budget preferences.
Historical PBM forensic audit
CG Moneta reviews 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 quantification
- Executive-ready findings and recommendations
Ongoing monthly PBM monitoring
Monthly monitoring can be selected independently or paired with a historical review. It helps organizations 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 monitoring
- Top drugs, pharmacies, patients, and utilization insights
- Continuous PBM accountability and oversight
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, contract enforcement, and improved monthly 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 have highlighted 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.
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.
Detailed cost analysis
Identify inflated pricing, hidden spread margins, claim overpayments, and undisclosed financial leakage.
Contract compliance review
Evaluate whether PBM execution aligns with pricing guarantees, rebate terms, audit rights, and fiduciary expectations.
Benchmarking and comparison
Compare pharmacy performance against contract expectations, market norms, pricing benchmarks, and utilization trends.
Recovery and renegotiation
Use audit findings to pursue recoveries, improve contract terms, and strengthen future PBM oversight.
Ongoing visibility into PBM responsibilities, contract guarantees, and pharmacy spend.
After the initial review, recurring reporting helps ensure no dollars are left on the table and PBM performance remains aligned with contractual obligations.
Contract guarantee monitoring
Audit PBM performance against contract guarantees for discounts, dispensing fees, rebate pass-throughs, and other financial terms.
Drug and utilization reporting
Identify top costly and frequently used brand, generic, specialty, and high-cost drugs driving pharmacy spend.
Pharmacy and member insights
Gain insight into top pharmacies, top patients, member cost trends, and claim utilization patterns requiring oversight.
Contingency where permitted. Flat fee where required.
Some PBM contracts permit contingency-based audits, while others restrict or prohibit them. CG Moneta 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, CG Moneta can 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 CG Moneta is compensated based on measurable results.
Flat-fee audit
When contingency fees are not allowed, CG Moneta can perform the PBM forensic audit under a fixed-fee structure based on scope, available data, number of plans, and complexity of the PBM arrangement.
Why passive PBM management leaves money and leverage on the table.
Protect margins. Strengthen leverage. Preserve patient trust.
PBM pressure is not limited to employer-sponsored plans. Independent pharmacies can 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.
Margin tracking and reimbursement
Compare reimbursement amounts to acquisition cost, NADAC, or other pricing benchmarks and identify drugs where reimbursement falls below cost.
Contract and PSAO oversight
Review PBM and PSAO performance, identify discrepancies, and determine whether contract economics are quietly reducing pharmacy margin.
Clawback and compliance protection
Gain visibility into high-risk claims, PBM red flags, audit exposure, and reimbursement behavior that may trigger chargebacks or penalties.
Negotiation leverage
Use defensible reporting and claims analysis to challenge unfair reimbursement, support renegotiation, and strengthen PBM-related decisions.
Specialized PBM audit leadership.
CG Moneta Consulting performs PBM forensic audit engagements in collaboration with Pharmacy Investigators and Consultants (PIC), a nationally recognized pharmacy benefit audit and healthcare fraud investigation firm led by Dr. Susan A. Hayes.
