Just three months into 2026, pharmacy benefit managers (PBMs) are already signaling that this year will bring stricter audit oversight than ever before. Any pharmacy owner who has experienced a PBM audit can tell you that each new year brings new findings and tactics designed to push independent pharmacies to the brink of financial collapse. The newest tactic involves increasing scrutiny of provider-patient relationships for a pharmacy’s dispensed prescriptions, even for provider-patient relationships that have long been established. Pharmacies that fail to provide sufficient documentation of a prior patient visit can find themselves at risk for significant recoupments, withholding of future payments for other claims, and potential network termination.

Under the Microscope: The Provider-Patient Relationship

Over the years, PBMs have become even more aggressive in their audit tactics. One of the most common ways PBMs seek to recoup payments from pharmacies is by looking for holes in the documentary record. Even one missing receipt or signature log can be the difference between a clean audit and thousands in recouped funds.

Recently, PBMs have focused on provider-patient relationships as a prime target for recoupments. Specifically, PBMs are closely reviewing the documentation provided by prescribers to pharmacies in support of prescription orders, including encounter summaries, medical charts, and visit notes. Pharmacies that fail to produce documentation to show that a valid provider-patient relationship existed—or fail to show that such documentation was considered and evaluated before a prescription was dispensed—are left scrambling when audit results come back, leaving them to rely on prescribers’ offices to protect them from PBM overreach.

But this isn’t the only way that PBMs use documentation to their advantage. PBMs often design their appeal processes with specificity, only considering distinct categories of documentation in the appeal process. In these cases, patient encounter documents that lack even small details, like appointment type or a prescriber’s fax header, may be entirely disregarded. Alternatively, some PBMs provide little to no guidance as to what type or amount of documentation is sufficient, leaving pharmacies guessing as to how to rebut findings effectively. PBMs regularly place pharmacies in this “documentation trap” during audits, even where the patient-prescriber relationship is well-established and known to the pharmacy.

Why Having the Right Documentation Matters

With any PBM audit appeal, having a strong documentary record is crucial. Without proof of a patient visit, pharmacies can easily be found accused of inappropriate dispensing activities. Requiring chart notes, encounter summaries, or other documents from prescribers demonstrating that a medication was prescribed appropriately protects the pharmacy from having a simple documentation discrepancy turn into an extensive investigation by PBMs, state medical boards, and even state and federal regulators.  

At HLA, We’re Here to Help

For small pharmacy owners, few moments are more stressful than receiving audit findings that outline thousands of dollars in recoupment, particularly for findings that are unreasonable, unsupported, or inaccurate. At Health Law Alliance, our PBM audit attorneys have unparalleled insight into how to beat PBMs at their own game, crafting meticulous appeals that keep your pharmacy in network and in business.  

Have you received audit findings but aren’t sure where to start? Contact our team today for a free consultation and learn how we can help.