February 4, 2016

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.

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI customized an audit plan to meet the following objectives:
  • Review 100% of all claims paid during a two year period.
  • Test claims against Summary Plan Descriptions, contracts and enrollment records.
  • Identify and analyze areas of possible fraud, waste, and abuse.
  • Confirm appropriate coordination of benefits.
  • Present detailed findings in addition to specific cost-savings recommendations based on the data and audit results.
  • Provide post-audit guidance and assistance.
Audit Finding:
  • Payment for impotence drugs and fungal medications which were excluded by the plan.
  • Payment for drug refills for patients with already over 100 days of supply on hand.
  • Failure to establish medical necessity for potentially cosmetic drugs.
Audit Outcome:

The PBM initially agreed to $12,000 in errors.  BMI assigned a dedicated Post-Audit Support Coordinator to walk the client through the findings and coordinate resolution of the issues identified as a result of the audit.

As a result of the post-audit dialogue, the PBM investigated and uncovered that some of the issues uncovered by the audit went back to 2009.  The PBM agreed to correct system edits and an additional credit of over $25,000 was issued as a result of the investigation.