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prescription drug claims audit

Medical & Rx Audit Yields Big Savings for Employer Group

Business Situation 

At the recommendation of their consultant following concerns about the accuracy of claims adjudication, this employer group approached BMI to conduct an audit of medical and prescription drug claims paid by their third-party administrator.

 

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the …

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Savings Follow Audit of Client’s Third-Party Administrator

Business Situation 

BMI was engaged to audit this manufacturer’s new third-party administrator for both their medical and prescription drug plans to ensure benefits were being paid appropriately and to evaluate overall administrative effectiveness.

 

Solution

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

  • Analyze
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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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Pharmaceutical Contract Review Yields Significant Cost Recovery

Business Situation:

This client engaged BMI to conduct a pharmaceutical claims audit and contract review of their self-insured pharmaceutical plans and third-party administrator (TPA), with an emphasis on whether all financial and performance guarantees were met per their pharmaceutical ASO contract.

Solution:

In addition to a full-service pharmaceutical drug audit, …

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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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Due Diligence Health Plan Audit Produces Unexpected Results

Business Situation:
With mounting pressure from their Internal Audit Department, our client selected BMI to conduct a medical and prescription drug claims audit solely for due diligence purposes confirming their fiduciary responsibilities.

Audit Finding:

While on-site, our auditors discovered payment errors on audit samples that included, but were not limited

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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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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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