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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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Pharmaceutical Audits Yield Significant Cost Recovery

Business Situation 

This public school district engaged BMI to conduct a pharmaceutical claims audit of their self-insured pharmaceutical plans and pharmacy benefit manager (PBM).  In addition, the client also engaged BMI to conduct an on-site rebate audit, as well as a complete contractual financial guarantee audit.

Solution

BMI performed three …

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PBM Auditing Beyond Just Claims Data – A Valuable Approach.

Audit Issue:    
Our client engaged us to conduct an audit of their pharmacy benefit manager (PBM) and Rx plan benefits which included a thorough analysis and testing of relevant ASO contract language stipulations related to several financial and performance guarantees.

Audit Finding:
During the course of carefully evaluating the

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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
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