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 gurantees 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