Each year, your group health plan pays for thousands of prescription claims. Yet without a pharmacy plan audit, employers are unaware if they are being billed correctly by their PBM for the prescription claims. Correct billing, improper use, and mounting problems are oftentimes unknowns, as well as, medication errors, incorrect discounts, and mistaken dispensing fees.
Self-insured employers need assurance that Pharmacy Benefit Managers pay prescription drug claims accurately and appropriately according to formulary and terms of the administrative agreement. To achieve this goal, HDM conducts a comprehensive review of PBMs including a claims audit and rebate audit to provide clients with the following:
| . Determine compliance with both contract terms and plan documents. |
| . Assess financial accuracy of paid claims and administrative processes, including error and fraud detection. |
| . Evaluate accuracy of payments and identify overpayments, duplicates cost savings prospects. |
| . Identify control weaknesses, their causes and suggest process enhancement/cost savings prospects. |
| . Assess retail and mail order programs. |
| . Review client's role regarding administration and offer recommendations. |
| . Identify, validate, and recover overpayments. |
The following services can be included in pharmacy plan audit:
Claims Audit
HDM analysis on 100% of prescription drug claims including retail and mail order programs.
Onsite Audits at PBMs
HDM auditors will visit the PBM to review the control environment, review claims analysis and perform a rebate audit. Auditors will evaluate the effectiveness of PBM policies and procedures in the administrator of the prescription drug program.
Rebate Audit
A rebate audit is conducted to determine the accuracy of rebate payments from the PBM to our clients. HDM will reconcile payments with claims data to ensure correct dollars were paid to our client by matching dollars paid to PBM within manufacturer contracts and formulary requirements.
Financial Reconciliation
HDM performs a financial and funding reconciliation, utilizing PBM reports and client banking records. We review adequacy of the funding requests and reconcile all funding and payment banking records, thus assuring there are adequate controls over financial transactions.
Recovery of Overpayments
HDM will present validated claim errors and overpayments to the administrator for recovery, as well as, negotiate and monitor recovery collection activity to ensure recovered dollars go to our client.
To learn more about our cost containment solutions for self-insured employers, contact HDM today at 800.859.5119 or request information with our online form. You may also send an email to: info@HDMinc.com.
|
