PBM Audits

The best contract language and financial terms in the world may go unrealized if the adherence and performance of your PBM is not tested and validated. Plan sponsors need assurance that their PBM vendor is paying claims accurately and in accordance with the terms and conditions of their service agreement.audit_detective_WBC_Baltimore

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 pricing requirements such as discounts, dispensing fees, co-payments 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.

This fiduciary oversight should be of particular importance to all Rx plan sponsors. Recent litigation brings to light the dangers to plans, to their administrators and to their plan officers or managers, both as plan representatives as well as exposing them to potential individual liability.

Our audits can include:

  • 100% of Rx claims including retail, mail and specialty to make sure pricing, discounts and guarantees are being met
  • Test that Prior Authorization and exclusions are being adjudicated properly
  • Compliance with plan documents to confirm that exclusions to coverage are being followed
  • 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
  • Retiree Drug Subsidy (“RDS”) from Medicare Part D to validate that eligible drugs are being submitted in order to maximize subsidy payments
  • Validate claims errors and over-payments to the PBM for recovery
  • Member cost sharing and co-payment accuracy

Additionally, our financial modeling will measure your PBM’s performance in order to evaluate the guaranteed effective discount rate, using both AWP and NADAC pricing benchmarks. This benchmark pricing is a much truer indication of actual acquisition cost and proves invaluable to the plan sponsor when accessing pass-through contracts and Maximum Allowable Cost (“MAC”) efficiency in order to assess whether your PBM is providing value.