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pharmacy benefits manager

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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Prescription Drug Claims Audit Uncovers 5 Years of Incorrect Adjudication

Business Situation:
BMI was engaged to audit this client’s contracted Pharmacy Benefit Manager (“PBM”) to determine whether claims were accurately adjudicated in accordance to benefit plan design, contractual pricing, and eligibility.


Solution:
Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI customized an audit plan to meet the following
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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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Pharmacy Benefit Manager’s Claims Payment Errors Corrected

Audit Issue:    
With an average of a half of a million dollars spent per month on prescription drug benefits, our client engaged us to conduct an audit of their pharmacy benefit manager to include extensive examinations of plan parameters such as:

  • Excluded and/or Limited Drug Types
  • Prior Authorizations
  • Copays
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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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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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