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.
Using our proprietary software AUDiT iQ™, we identified paid claims for acne medication where the members had exceeded the minimum age required to receive the drug. In addition, paid claims were also identified for fertility drugs and for drugs where a prior-authorization was required but was not done.
The claims administrator acknowledged that their system had not been properly configured for the acne drug age edit. They also acknowledged that an appropriate rule was not in place to exclude fertility drugs and that a prior-authorization rule was not in place for the drug Lamisil.
The administrator agreed to financial errors exceeding $23,000.00.