Ethica Auditing Services: From Spreadsheets to Digital

Ethica’s PBM audit services

Ethica’s digital-first approach supports a range of PBM audit services designed to validate contractual performance, uncover financial risk, and strengthen plan oversight, including:

How the audit process works

The exact audit timeline varies based on the audited organization and type of audit. Audited organizations frequently specify allowable response times in their contracts for providing data, answering questions, and reviewing audit results.

Scope & Alignment
Define audit objectives, scope, and expectations with the client.

Data Collection & Validation
Request, receive, and perform a data integrity check to ensure accuracy and completeness prior to analysis.

Audit Execution
Analyze data against contractual and operational requirements.

Findings Review & Confirmation
Review findings, conduct internal quality review, and review results with the PBM prior to finalization.

Final Reporting & Impact
Deliver finalized and agreed upon findings and actionable insights to support informed decisions.

Automation vs. manual audits

Discoveries between expected & actual data

One critical step during the audit process is performing a data integrity check. At Ethica, we place a strong emphasis on this step, as an audit performed on inaccurate or incomplete data compromises the reliability of the results. Our team uses automated data flows to perform data range, type, and other validation tests.

Ethica’s automated data integrity process quickly identifies data errors and incomplete data sets provided by the audited organization enabling timely resolution, minimizing audit delays, and ensuring audits are performed on complete and reliable data sets protecting overall audit integrity.

What can audits reveal beyond costs

In addition to potential financial audit recoveries, audits reveal areas of improvement that can be leveraged in future contract negotiations and plan design decisions. These areas of improvement may include uncompetitive financial guarantees, unintended drug coverage, incorrect plan implementation, and more.

An Ethica Client Example: During a recent audit of a specialty pharmacy carve-out vendor, Ethica identified an opportunity to strengthen the client’s contract. The audit revealed that the existing contract did not include any financial guarantees. Following the conclusion of the audit, Ethica began working with the client to negotiate the addition of financial guarantees to the contract, or alternatively, evaluate the option to carve their specialty pharmacy benefit back into the plan.

What can you expect from Ethica

• Objective, independent audits
• Technology‑driven consistency and accuracy
• Transparent, clearly communicated findings
• Recommendations aligned to your plan goals
• Supported by in‑house clinical, legal, and compliance experts

Key Takeaways

Ethica’s independent audits combine data integrity, a digital‑first methodology, and expert review to validate contractual performance, uncover discrepancies, and identify opportunities to strengthen plan design. By turning audit insights into long‑term value, Ethica supports smarter, more accountable benefit decisions. Explore how Ethica’s Auditing Services strengthen oversight and support better outcomes.