June 4, 2018

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.


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

  Audit Findings

  • 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

  Audit Outcome

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.