To design an effective CVS Caremark audit response strategy, providers must understand the chain of events both prior to the initiation of a CVS Caremark audit and afterwards. For example, Special Investigative Units (SIUs) are often the genesis of a CVS Caremark audit, and the presence or absence of "audit risk factors" is informative on potentially broader exposure beyond the CVS Caremark claims under audit. Any decision to resolve a CVS Caremark audit should be informed and result in a full and final settlement of all liability, but CVS Caremark audit settlements need to be structured carefully to achieve this goal.

CVS Caremark, OptumRx, and Express Scripts, control at least 80% of the market, making them the three biggest PBMs. Humana also ranks among the largest. In addition, these PBMs regulate access to networks for smaller competitors, such as ESI's partnership with Prime. Plan sponsors, such as United Health, Cigna and Aetna, are vertically integrated with these PBMs, increasing CVS Caremark audit risk for pharmacies because network sanctions are more likely to affect a significant aspect of a pharmacy's business across both government and commercial claims.

PBMs like CVS Caremark and payors use artificial intelligence and data mining across medical and pharmacy claims to identify areas of potential inquiry. Among other areas, these inquiries typically involve high-reimbursing medicines, brand/generic substitution, inventory discrepancies, co-payment collection, prior authorization, and telehealth relations. Separately, DEA conducts audits and inspections for compliance to controlled substance regulations.  

Common types of CVS Caremark audits include desk audits; on-site audits; invoice audits; and prescription audits. Irrespective of the type of CVS Caremark audit, all interactions with CVS Caremark should be taken extremely seriously and can lead to severe consequences if not handled appropriately. For example, there has been a sharp increase in the federal prosecution of pharmacists for audit-related conduct, including answering PBM questions incorrectly. Accordingly, pharmacies should consider using CVS Caremark audit counsel to avoid these pitfalls.

Pharmacies can take various steps to prepare to meet CVS Caremark audits, including routine self-audits. In fact, the government publishes comprehensive guidance and a checklist to assist pharmacies in their audit planning, including self-audits around prescribing practices, controlled substance management, invoice management, and billing practices. If you need assistance designing or implementing a CVS Caremark audit protection plan, please do not hesitate to contact us.

Defending against a CVS Caremark audit requires comprehensive knowledge of the rights, responsibilities, and intricacies of pharmacies and their laws and regulations.  If your pharmacy has been identified for a CVS Caremark audit, there are a number of potential defenses available to you. The first defense against a CVS Caremark audit is to be proactive, and audit planning can lessen the chance of unfavorable findings. That said, it is often necessary to involve an attorney to hold PBMs like CVS Caremark accountable to their obligations under law and provider agreements. For this reason, national audit services and pharmacy audit consultants are often ineffective.

CVS Caremark audit discrepancies and findings can be appealed based on the specific procedures outlined in the provider manuals. It is important to follow these requirements exactly, within the timeframes established, or your CVS Caremark appeal rights could be lost and further review denied. In a CVS Caremark appeal, it is critically important to make a complete record of why the CVS Caremark audit findings or sanctions should be reversed, including through documentation, legal arguments, and corrective actions, if any. Depending on the outcome of the CVS Caremark appeal, you may have further legal recourse against CVS Caremark.

CVS Caremark audits can have severe repercussions depending on the results of the pharmacy audit, including recoupments, network sanctions, and criminal, civil and administrative investigations involving jail time, significant fines, and license revocation or exclusion. We publish a 10-part PBM Audit Guide that discusses the overlap between CVS Caremark audits and government investigations and how to successfully manage CVS Caremark audit risk. This resource is complimentary to subscribers HERE.