Every claim, under the contract as written, reproduced before it is challenged.
The contract first
We read your agreement, every amendment, every pricing exhibit, and the lists that change the price (specialty, exclusions, the program lists). Each term becomes a rule with the clause it came from, dated to when it took effect. Where a term can be read two ways, we record both and a pharmacist decides which the contract supports; that decision is written down with the finding.
Then the claims
Your year of claims is mapped to one layout and checked before anything is priced: totals have to tie to the PBM's invoices, member months to your eligibility file, and reversals have to net correctly. If the data does not reconcile, we say so before we say anything else.
Re-pricing
Every claim is priced under the contract in force on the day it was filled: the discount it should have carried, the fee, the rebate it should have earned, the program that should have applied, whether the member was eligible. The result is compared with what the PBM charged, and the difference is a finding only when it is a breach of a term, not a disagreement about what a term should have said.
The PBM's number first
Before we raise a finding, we reproduce the PBM's own reconciliation number from their method. That is a check on them, not the standard: every claim is priced against an independent reference price for the day it was filled, never against the price in the PBM's own file, and a gap between the two is itself a finding. If we cannot reproduce their number, that is reported as its own finding. If we can, every difference we then raise is a documented disagreement, clause by clause, that the PBM cannot wave away as a difference of method.
Arguing their side
Each finding is tested against the way PBMs actually respond: a later amendment, an exclusion, a definition, a netting clause, a timing argument. Findings that would not survive are dropped. The ones that remain go to the PBM with the rebuttal already answered.
What a person does
The audit is run by software and signed by a pharmacist. Shawn reviews every contract reading the software was not certain of, every finding that is new or large, and a random sample of the rest. He does not read every claim; the software checks every one.
Why it can be re-run
Every audit is pinned to the exact documents, rules and data it used, and the record of that is sealed where it cannot be changed. Months later, during the true-up, the same audit can be re-executed and must produce the same result. The audit run never uses an AI model, which is what makes that possible; models are used only to read documents and draft narrative, and what they read is confirmed before it is used.
Accuracy
Every claim is checked by software; none is scored by hand. Before any finding counts, the software must reproduce the PBM's own reconciliation totals, and the main pricing rules are computed two independent ways that must agree on every claim. It is tested against a synthetic plan with known errors planted in it, including errors it has never been shown, and scored against an answer key kept apart from the software's code and from everyone who writes it. On a real audit, the PBM's response to each finding is the field check. We publish our uphold rate, the share of findings sent to PBMs that are accepted, once there is a history to publish.
Data handling
Business associate agreement and NDA before any file moves. Your plan's data sits under its own encryption key in our US cloud and no other plan's audit can reach it. Member identifiers are hashed on arrival. No one on our side has standing access to plan data; emergency access is time-limited and logged. We will show your privacy officer the one-page analysis of why claim-level data is the minimum necessary.
Published audits, not OwedRx engagements
These are audits other auditors ran and published: a federal inspector general, and a benefits consultant working for a public plan. They are not OwedRx engagements and not OwedRx results. They show what an audit finds when someone finally looks.
A federal employee health plan
U.S. Office of Personnel Management, Office of the Inspector General
$44.9 million in questioned costs: drug discounts, credits, rebates and fees the plan's PBM had not passed through as its contract required, over contract years 2016 to 2021.
A public school purchasing agency covering more than 30,000 people
Segal, the plan's benefits consultant
$4.6 million in undistributed discounts and rebates owed to the plan, found in a claims audit of its PBM.
Source: Segal, published case study: PBM audit of discounts and rebates
Plans of a few thousand people have the same contracts and have almost never been audited.