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December 12, 2011

BMI Audit Finding of the Month: Prescription Drugs Did Not Get the Required Prior-Authorization

Audit Issue:
The terms of our client’s group pharmaceutical plan specifically stated that benefits for certain drugs could not be paid unless prior-authorization was obtained on behalf of the participant.
Audit Finding:
We confirmed that benefits were paid on more than 100 occurrences when the prior-authorization requirement was ignored by the Pharmacy Benefits Manager (PBM).
PBM Response:
The PBM agreed with our findings noting that prior authorization criteria had been erroneously eliminated from its system without detection.
Financial Error:
The PBM agreed to recoverable financial errors of more than $50,000.