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.
BMI performed three full-service pharmaceutical drug audits which included:
- Plan Compliance – member / plan cost share, excluded / limited drugs, prior-authorization, days supply, step-therapy, and others.
- Fraud/Waste/Abuse – duplicate scripts, refill too soon, provider profiling issues, abuse and addictive agents, and others.
- Eligibility – claims paid when not eligible, no eligibility.
- Contractual Financial Guarantee Audit: AWP discounts, dispensing fees, and other consultative recommendations.
- On-site Rebate Audit
- Financial guarantee AWP discount calculation error, in a retail setting:
- $780,000 recovered
- Health Care Reform compliance errors with respect to contraceptive drugs:
- $210,000 recovered
- Rebate payment errors:
- $45,000 recovered
- Prior-authorization not performed correctly:
- $25,000 recovered
As a result of the above audit findings, BMI identified over $1,060,000 in payment errors that were successfully recovered back to the client.
Learn more about pharmaceutical claims audits here.