Annual Pharmaceutical Audit Uncovers Systemic Errors

Business Situation

This large county government engages BMI to conduct annual pharmaceutical claims audits of their self-insured pharmaceutical plan and pharmacy benefit manager (PBM).  In addition, the client also engaged BMI to conduct a contractual financial guarantee audit.

Solution

BMI performed 2 full-service pharmaceutical drug audits which evaluated areas such as:

  • 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 member was not eligible, no eligibility

Audit Findings

  • Quantity limits not applied correctly

  • Refills without appropriate prior authorization

  • Deductibles not considered while calculating member liability

  • Identification of drug “spread” pricing practices and recommendations on key contractual changes

Audit Outcome

The PBM agreed to initial overpayment amounts exceeding $13,000 and committed to providing an impact assessment and remediation plan to identify all impacted claims which BMI estimated to be an additional $36,000. Contractual language changes were taken under consideration ahead of renewal.

At the conclusion of the audit, BMI assigned a specialist to walk through a variety of additional recommendations and solutions to resolve and prevent future claims processing errors from occurring.

Contact us to learn more about our solutions.