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drug exclusion

Claims Audits – An Immediate and Future Cost Reduction Strategy

Business Situation 

This county government client approached BMI to conduct an audit of medical and prescription drug claims for cost reduction purposes after a significant rise in insurance expenditures.

 

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all medical
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Prescription Drug Payment Errors Prove Costly Following Audit

Audit Issue:    

Client plan language indicated 1) an age edit rule for acne medication, 2) an exclusion for fertility drugs and 3) a prior-authorization requirement on several drugs.   
 

Audit Finding:

Using our proprietary software AUDiT iQ™, we identified paid claims for acne medication where the members had

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PBM’s System Not Correctly Programmed: Approvals Given Despite No Prior Authorization

Audit Issue:    

We reviewed prescription drug plan claims data provided for any potential systemic error issues regarding exclusions, drugs requiring prior authorizations, limitations, etc.

 
Audit Finding:

Though the plan excluded drugs or supplies used for the treatment of erectile dysfunction, impotence or sexual dysfunction or inadequacy, multiple drugs used …

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