Recurring Pharmaceutical Audit Continues to Prove Beneficial

Business Situation

For over 10 years, this large public school district has engaged BMI to conduct annual pharmaceutical audits of their prescription drug plans and pharmacy benefit manager (“PBM”).

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 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-savings recommendations based on the data and audit results.

Audit Findings

  • An 87-day supply of a drug refilled 51 days later

  • Drugs refilled beyond a member’s termination date

  • Discrepancies between plan member and PBM documentation for prior authorization

Audit Outcome

The PBM agreed to initial overpayment amounts close to $24,000 citing incorrect plan programming as the cause for many of the issues identified. These findings provided additional opportunities to ensure the PBM’s systems and documentation practices remain consistent with plan intent.

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