Reasons to Audit Your Prescription Drug Claims

With more than 4.5 billion pharmacy claims occurring each year, it's easy for a self-funded employer to pay the claims without questioning whether they're accurate or not. However, on average, errors are found in about 3-5% of claims, resulting in recoveries of about 1-2%. That alone should be enough to peak your interest in learning more about how you can get a free claims analysis. If you're still on the fence, take a look at some other reasons to audit your prescription drug claims.


Audits help to catch expensive coding errors.
Because most claims are automatically adjudicated electronically, even a minor coding error can result in a large number of incorrectly paid claims with a serious financial impact. Common errors may include duplicate billing, incorrect or missing discounts and rebates, and mistakes in member eligibility. A comprehensive audit checks every claim during a fixed period of time to assure compliance with contractual guarantees.

Audits verify that the benefits spelled out in the contract are being provided.
The goal of a claim audit is to verify the accuracy of claim payments according to the contractual agreement. The objectives are to confirm that the plan is being administered in compliance with contractual obligations and that the plan sponsor is receiving all benefits of the contracted arrangement. We also review whether claim cost management features and clinical protocols are being administered appropriately and are providing the intended value.

Audits examine financial, plan design, claim eligibility, rebates and performance guarantees.
An audit typically examines financial elements, plan design, claim eligibility, rebates and performance guarantees. It assesses whether the contracted pricing arrangement is being properly applied and reviews all records for possible duplicate payments. The audit also evaluates the accuracy of member cost sharing and checks for compliance with formulary and generic product provisions as needed. The audit also compares plan eligibility files to claim files to verify claims were paid only for covered members and their dependents from their effective dates to their termination dates.

A PBM audit is a potential opportunity to recover funds lost through over payment or system errors. It can help to identify parts of a plan that may need improvement, areas that could be cut to preserve spending, and can show you areas in which you can save money by adjusting copays and making changes to the approved prescriptions list your employees can choose from.

So, if you're a self funded employer who feels they're paying way too much for their prescription drug plan – we have solutions for you! Trust in the best Pharmacy Benefit Management service provider in Missouri to complete a FREE no obligation claims analysis! We'll help you pinpoint the areas that need improvement and help you save money in the process!

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