Rivera examines why federal and state pharmacy benefit reforms demand continuous, claim-level monitoring, not just new rules

Rivera, an independent pharmacy payment integrity company, published a new issue brief examining why the current wave of PBM reform raises the bar for pharmacy benefit oversight without replacing the need for it.

Recent federal and state actions have increased scrutiny of how pharmacy benefits are administered, including changes tied to Medicare Part D, ERISA disclosure expectations, and broader oversight of PBM practices. But legislation alone does not verify whether new contract terms, pricing structures, and regulatory requirements are being applied correctly at the claim level.

The brief, titled “Reform does not enforce itself: Why PBM legislation demands continuous oversight,” argues that this verification gap requires a new operating discipline: continuous oversight of pharmacy claims.

The issue brief details how reform has shifted the pharmacy benefit landscape in four key areas: PBM compensation models are moving toward delinked fees and full rebate pass-through; disclosure and audit expectations are expanding under the proposed DOL rule; regulatory and political focus on PBM practices has become sustained rather than episodic; and state-level requirements continue to stack across licensure, spread pricing, and network rules. Each of these shifts must ultimately be reflected in contracts, benefit designs, and claims configuration, and each creates new opportunities for errors that traditional periodic audits are not designed to catch in real time.

“The conversation has shifted from whether PBMs should be more transparent to whether that transparency is actually being verified,” said Ron Hamm, CEO of Rivera. “Health plans that treat reform as a reason to ease up on oversight will still be accountable for every dollar that runs through their pharmacy benefit. Continuous monitoring is how plans turn reform into measurable value, not just compliance.”

Rivera’s continuous monitoring platform evaluates 100% of pharmacy claims against benefit design, contract terms, and regulatory requirements using more than 750 proprietary algorithms. Unlike traditional retrospective audits, which typically review a sample of claims months after a plan year closes, Rivera’s approach surfaces discrepancies on an ongoing basis, enabling dollar recovery and preventing repeat errors.

The full issue brief is available at this link.

About Rivera

Rivera is an independent pharmacy payment integrity company that helps health plans and employers verify that pharmacy claims are adjudicated according to benefit design, contract terms, and regulatory requirements. Through continuous monitoring of 100% of pharmacy claims, Rivera identifies overpayments, resolves root causes to prevent recurrence, and delivers data that strengthens PBM negotiations. Rivera is not affiliated with any pharmacy benefit manager. Learn more at riverarx.com.

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