What health plan leaders say about claims accuracy, PBM oversight, and the gap between expectation and execution
What health plan leaders say about claims accuracy, PBM oversight, and the gap between expectation and execution
14
14
health plans surveyed
26M+
26M+
covered lives represented
01
Executive summary
Pharmacy claims are the largest single category of health plan expenditure that no one continuously verifies. Plans negotiate complex contracts, design detailed benefit structures, and then trust that billions of dollars in claims are adjudicated correctly, with little infrastructure to confirm it.
Rivera's 2026 research with pharmacy executives at 14 health plans, collectively covering more than 26 million lives across commercial, Medicare, and Medicaid lines of business, reveals a consistent pattern: payers know their claims have problems, their teams lack the capacity to find them at scale, and the traditional audit model leaves gaps measured in months and millions of dollars.
This report presents findings from two distinct sources: industry-level payer research reflecting how pharmacy leaders experience the oversight gap, and Rivera's own operational data illustrating what continuous monitoring reveals. Both are labeled throughout so the reader always knows which lens they are looking through.
About this report's data sources
Payer research
Perspectives of pharmacy executives at 14 health plans covering 26M+ lives. Describes the industry landscape: claims issue frequency, monitoring priorities, labor burden, buying dynamics, and organizational barriers.
Rivera operational data
Outcomes from Rivera's continuous pharmacy claims monitoring. Algorithm distributions, finding patterns, and financial outcomes are specific to Rivera's technology and methodology, not industry benchmarks.
02
The oversight gap is real and widely acknowledged
Payer research
Health plan pharmacy leaders do not need to be convinced that claims errors exist. They live with them. In Rivera's 2026 payer research, nearly half of pharmacy executives described claims issues as frequent occurrences within their organizations.
How often do pharmacy claims issues occur at your organization?
Frequently
50%
Occasionally
36%
Almost always
8%
Rarely
6%
This finding carries more weight given the profile of respondents. These are vice presidents, chief pharmacy officers, and directors of pharmacy at organizations managing hundreds of thousands to millions of covered lives. What they see is a system that consistently underperforms the terms it was built to honor.
The problem is not ignorance. Plans know errors exist. The problem is detection infrastructure. Most organizations rely on point-in-time audits that review a sample of claims 12 to 24 months after they were paid.
03
What payers prioritize in monitoring
Payer research
When asked to rank their monitoring priorities, pharmacy executives coalesced around a clear hierarchy. Pricing benchmarks and lesser-of-logic compliance ranked highest, alongside performance guarantees and contractual terms.
Payer priorities in monitoring pharmacy claims
Pricing benchmarks & lesser-of logic
24%
Performance guarantees & contract terms
22%
Benefit & utilization controls
20%
Prior authorization & clinical edits
16%
Coordination of benefits & eligibility
10%
Discount & affordability programs
8%
Priorities in proof points for internal stakeholders
Financial impact and ROI
32%
Risk reduction & compliance
22%
Operational efficiency
16%
Visibility into PBM performance
14%
Executive or peer validation
10%
Clinical or member impact
6%
The primary frame is financial accountability, not clinical optimization. Payers want to know they are paying what they agreed to pay. The entry point for investment in oversight infrastructure is financial.
04
The labor problem: why internal teams cannot keep up
Payer research
Even when plans recognize the oversight gap, most lack the internal capacity to close it. Rivera's research identified data manipulation and validation as the most labor-intensive aspect of pharmacy oversight.
Data manipulation and validation
Raw data from PBMs requires extensive manual reconciliation before meaningful analysis. Claims adjudication validation, performance guarantee reconciliation, and data accuracy checks consume significant staff hours, recurring with every reporting period.
Contract compliance and reconciliation
Multi-layered PBM agreements covering pricing, network access, formulary management, clinical edits, and performance guarantees. Verifying each provision at the claim level requires domain expertise many organizations struggle to maintain.
Organizational misalignment
Pharmacy teams absorb oversight responsibilities from other departments. FWA teams may lack pharmacy-specific expertise, so the work defaults back regardless of org structure. The people best equipped to find issues are already overextended.
Larger systems
More often cite data validation, manipulation and reconciliation as primary burden
Regional plans
More frequently cite bandwidth, manual follow-up, and staffing constraints
05
Why traditional audits fall short
Payer research
The standard pharmacy benefit oversight model follows a predictable cycle: a plan conducts a PBM procurement or market check, operates for one to three years, then commissions a retrospective audit. This model has three structural weaknesses.
1
Retrospective and narrow in scope
A typical PBM audit reviews a defined set of claim categories 6 to 12 months after the plan year closes. Issues outside audit scope go unexamined.
2
Compounding exposure window
An adjudication error starting in January may not be identified until an audit completes in June of the following year. That is 18 months of incorrect processing before the plan knows.
3
Findings without root-cause resolution
Point-in-time audits identify errors but do not monitor whether corrections hold. PBM configuration changes can introduce new issues.
The traditional oversight gap
PBM procurement
Year 1 (no oversight)
Year 2 (no oversight)
Audit
Findings
12 - 24 month gap between error onset and detection
06
What continuous monitoring reveals
Rivera operational data
Rivera's proprietary algorithm library, built from over a decade of claims analysis across multiple PBMs and plan types, provides a window into the types and scale of claims issues that continuous monitoring uncovers. While no single vendor's experience represents the entire industry, these patterns illustrate what becomes visible when every claim is monitored against every contractual and plan design provision.
ri
Algorithm library breakdown
Plan design error (47%)
Savings opportunities (15%)
Audit review (13%)
Claim fill error (12%)
Contract error (10%)
Reimbursement review (3%)
65%
broader claims oversight
vs. traditional audit methods
In Rivera's experience, standard PBM audits cover roughly 35% of the issue landscape. The remaining 65% falls outside what most plans evaluate.
Several categories of findings recur across plan types and PBMs with enough consistency to suggest systemic rather than incidental causes.
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Finding patterns across Rivera's client base
NADAC lesser-of-logic failures
Brand/generic misclassification overrode state-mandated lesser-of-logic, causing plans to pay above the mandated floor.
$2.1M
Recovered dollars
$4.2M
Avoided spend
$6.4M
Total resolution
Drug discount card lesser-of-logic
PBM was not incorporating discount card pricing into lesser-of adjudication on every claim.
Override codes at a large pharmacy chain improperly bypassed COB adjudication logic.
$4M
Current year
$2M
Retrospective
$6.1M
Total credited
Specialty drug pricing gaps
New-to-market specialty drugs continued adjudicating at default rates instead of negotiated contract rates.
7
Drugs adjusted
~AWP-8%
Default rate
~AWP-20%
New rate
$3.8M
Guarantee improvement
$100M+
identified savings
across Rivera's health plan client base
100%
of clients
recover their investment in year one
07
Continuous monitoring: a category takes shape
Payer research
The concept of monitoring 100% of pharmacy claims on a continuous basis is new enough that the industry has not yet settled on a single term for it. Rivera's research tested multiple descriptors with payer executives.
How payer decision-makers describe 100% pharmacy monitoring
Pharmacy payment integrity
48%
Continuous oversight
24%
Performance validation
10%
Audit and recovery
8%
Cost avoidance/containment
6%
Vendor accountability
4%
Ongoing detection
Issues identified as they occur, not months after. Most consistently cited differentiator.
Compounding value
Algorithms learn from findings across clients. Year one is the floor, not the ceiling.
Neutral event framing
Recoveries are dollars the plan should already have. No members or providers are harmed.
Resource efficiency
Replaces or augments internal audit capacity without adding staff.
08
The buying landscape
Payer research
The champion is in pharmacy
The pharmacy leader must introduce this capability. When anyone else brings it forward first, it undermines the pharmacy team's credibility and authority.
Budget timing is the primary barrier
The obstacle is not skepticism. Realistic timelines: 6-12 months, extending to 12-18 if the budget cycle has closed. Optimal entry: 12 months before PBM renewal or RFP.
PMPM with ROI guarantee is the preferred model
Shared savings models have lost favor. Disagreements over what counts as savings, actuarial barriers, and disputed findings make them adversarial. PMPM with guaranteed ROI resolves all three.
PBM conflict is a perceived risk that practitioners dismiss
Executives raised the concern and dismissed it themselves. In the current regulatory environment, PBM resistance to plan-sponsored oversight is politically untenable.
MLR implications require proactive planning
Adding an administrative vendor cost can worsen MLR ratios. Creative approaches include pharmacy management fund dollars, reclassification from admin to medical cost savings, and hybrid structures.
Required stakeholders for procurement
Pharmacy leadership (champion)
Vendor/procurement
Compliance & legal
Finance & actuarial
IT
09
Emerging applications beyond cost recovery
Payer research
While financial recovery is the entry point for most plans, the research identified five applications of continuous claims monitoring that extend beyond the core value proposition.
Medicaid recoupment prevention
Continuous monitoring surfaces adjudication issues before state audit processes identify them, shifting from reactive defense to proactive compliance.
PBM carve-out deterrence
Demonstrating ongoing, independent validation of claim integrity gives health plans a competitive retention tool for employer group clients considering pharmacy carve-outs.
Risk adjustment opportunity
Improvements in claim accuracy can surface missed risk adjustment coding opportunities, particularly in Medicare Advantage populations.
Contract language advisement
Intelligence from monitoring applies directly to PBM RFPs and renewals. Plans gain visibility into how their PBM interprets specific contract provisions.
Stars program adjacency
Claims monitoring data may support Stars-related quality measures, broadening the internal buying coalition across multiple budget owners.
10
What comes next
The pharmacy payment integrity category is at an inflection point. The oversight gap is validated by the payers who live with it every day. The demand signal is strong. The regulatory environment favors transparency and accountability. And the traditional audit model is structurally incapable of addressing the scope of the problem.
For pharmacy leaders considering where to start, the research points to a clear path: begin with the areas of highest financial exposure, specifically pricing and lesser-of-logic compliance, plan design error detection, and performance guarantee validation. These categories consistently ranked highest in payer priority surveys.
The plans that move first will have a structural advantage.
They will identify and resolve issues sooner, enter contract negotiations with better data, and build an operational capability that compounds over time.
The data is clear. Hope is not a strategy.
Where does your organization stand?
This report describes the pharmacy payment integrity landscape as payer leaders experience it. But every plan's exposure is different. The gap between what you negotiated and what your PBM is delivering depends on your contract structure, your plan design complexity, your lines of business, and the oversight processes you have in place today.
Rivera's pharmacy oversight assessment is a 13-question diagnostic designed to help pharmacy leaders identify where their organization falls on the oversight spectrum, from fully covered to structurally exposed. It takes less than two minutes and produces a personalized readiness profile you can use internally or share with your leadership team.
