Pharmaceutical Audit Reveals over $500,000 in Errors

Business Situation

This major metropolitan hospital engaged BMI to conduct a pharmaceutical audit of their prescription drug plan and pharmacy benefit manager (“PBM”) to ensure claims were being processed correctly.

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all prescription drug claims paid by the PBM during a 24-month period.

  • Test claims against plan compliance, eligibility and  areas of possible fraud, waste, or abuse.

  • Audit a sample of claims based on the analysis.

  • Present detailed findings and specific cost-savings recommendations based on the data and audit results.

Audit Findings

  • Fertility medications covered beyond the maximum benefit coverage of $15,000

  • Failure to obtain prior authorization on high-cost drugs over $10,000

Audit Outcome

The PBM agreed to initial overpayment amounts of $19,500 citing incorrect coding as the root cause for many of the issues identified. Additional claims with related issues totaled over $500,000. The PBM agreed to conduct impact studies in order to reveal the overall financial impact to the plan.

At the audit’s conclusion, BMI assigned a specialist to walk through a variety of recommendations including additional short and long-term solutions in order to prevent these types of errors or discrepancies from continuing to occur.

Pharmacy Claims Audit, Healthcare Claims AuditRobert Temples