Stemming the Tide of Pharmacy Copay Misprocessing
Roughly one in ten pharmacies engages in copay misprocessing, a quiet drain on pharmaceutical affordability budgets that compounds into billions of dollars in industry-wide leakage. As reimbursement pressures mount, manufacturers are finding that traditional retrospective audits are increasingly failing to protect their gross-to-net performance.
Pharmaceutical manufacturers often overlook the mechanics behind copay claim manipulation, yet these small-scale discrepancies aggregate into significant financial loss. Common tactics—ranging from claim markups and code switching to invalid BIN usage—are becoming more prevalent as pharmacies face tightening margins. The risks are further amplified by the rise of self-pay and direct-to-patient channels, which create new avenues for exposure that automated, pre-payment flagging systems frequently miss.
To address these vulnerabilities, RIS Rx co-founders Gerard Rivera and Stephen Hom will host a webinar on August 24, 2026, at 1 p.m. EDT. The session will move beyond theory to examine how real-time claim analysis paired with PharmD-led intervention can successfully deter misuse. By shifting from reactive audits to active, pharmacist-led oversight, manufacturers can reclaim lost spending and ensure that affordability programs continue to reach intended patients.
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