12,500+ Prescriptions Impacted by PBM Mistake

Business Situation

To ensure the correct processing of prescription drug claims, a nationally recognized electronics and technology company engaged BMI to conduct an audit of their pharmacy benefit manager (“PBM”).

Solution

Utilizing 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 12-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-saving recommendations based on the data and audit results.

Audit Findings

  • Failure to apply drug-specific copays across various brand drugs impacted over 12,500 prescriptions filled by members.

Audit Outcome

As a result of the audit, claims were reversed and re-processed.

The PBM agreed to a credit amount of $267,290 to the employer citing incorrect plan setup as the root cause for the systemic issue identified. The PBM also reimbursed $185,725 to 820 members impacted by the mistake.

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