PBM Performance Audits

WBC Audit Detective

The best contract language in the world may go unrealized if the adherence and performance of the PBM is not tested and validated. Plan sponsors need assurance that their PBM vendor is paying claims accurately and in accordance to the terms and conditions of their service agreement. Our audit services will focus on 100% of pharmacy claims for the selected review period to provide a comprehensive analysis. The audit can include compliance with contractual requirements such as discounts, dispensing fees, copayments and guarantees; rebates; operations; and customer service. An audit will also help identify unusual prescribing patterns, excessive utilization, fraud, waste and abuse. Audits also demonstrate to the plans’ stakeholders that plan management has taken appropriate fiduciary action to investigate the plans’ performance and hold vendors accountable. Our audits include:

  • 100% of Rx claims including retail, mail and specialty to make sure pricing, discounts and guarantees
       are being met
  • Onsite visits to the PBM to review control environment and evaluate effectiveness of policy and procedures.
  • Rebate audit to determine accuracy of payments and reconcile payments with claims data as specified in manufacturer contracts and
       formulary requirements
  • Financial reconciliation to make sure there are adequate controls over PBM financial transactions related to the client's account
  • Validate claims errors and overpayments to the PBM for recovery

PBM Invoice Validation Service

Every two weeks in the U.S., $12 billion in pharmacy benefit claims (PBM invoices) are paid by plan sponsors without review. Mistakes due to systems problems, coding errors, complexity of PBM contracts and ever-changing pricing discounts lead to errors. Without concurrent invoice review, a plan sponsor is probably paying significantly more than they should!

Our technology identifies overcharges BEFORE payment is made. Bill review is not new in health care, since a majority of medical claims are reviewed prior to payment.  However, it’s just about never done in pharmacy and NEVER with the detail, speed and accuracy we deliver!

WBC provides this critical, prepayment review service for prescription claims.  Our clients receive an immediate ROI with the first invoice we review. The review includes:

  • Ingredient costs
  • Effective discount rates
  • Dispensing fee validation
  • Member cost share
  • Invalid NDCs

  • Duplicate claims
  • Fraud, waste and abuse
  • Eligibility review
  • Medicare Part D subsidy
  • Regulatory compliance

Automated patent-pending technology reviews and analyzes unlimited claims data. We have a proven, HIPAA secure and PBM-agnostic platform that has reviewed more than 100,000,000 claims serviced by all PBMs. The system is fully scalable, easily handling large or small claims volumes. Our clients include government entities, health insurance companies, self-insured employers and Taft-Hartley welfare funds. Unlike end-of- contract audits that are difficult to gain recoveries, our monthly monitoring provides cash flow controls and near real-time reporting delivered within hours of obtaining the necessary data feeds. Discrepancies can be fully documented and deducted from that month’s invoice. Contact us to see how much you can save.

PBM Invoice Validation Service

AVERAGE SAVINGS OF 3-5% OF DRUG SPEND

Adequate financial oversight is not just a compliance afterthought, it's a necessity!  Our reviews help reduce fiduciary liability by improving regulatory compliance for Sarbanes-Oxley, Medicare Part D, GASB 45 and FAS106. Our system has the ability to maintain a parallel reconciliation process aligned with internal audit and financial reporting calendars.

Find out what our invoice review service can do for you. Monthly monitoring provides continued cash flow control, cost reduction and compliance validation. Try it at no cost or risk, with the first month's service free.
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