The Big Opportunity of Pharmacy Claim Audits

[TFGPartners]

The ever-higher prices for new medications make news continually large employers self-funding employee benefits often bear the brunt. Therefore, running an Rx audit frequently makes sense to double-check claims paid. More than a few high-priced on-patent medications offer rebates and discounts to volume buyers, and audits help confirm your plan is credited. Today, pharmacy benefit managers (PBMs) are achieving ultra-low error rates, but running oversight on their work with high prices is sensible. It's also cost-effective because audits typically find errors amounting to more than their price.

There was a time when plan sponsors might have had an in-house claim administration capability, but outside providers have been the norm since the arrival of managed care. PBMs bring advantages and have deep immersion in the market. Their expertise and experience are beneficial in many ways, but no one is perfect, and auditors can review their work. Even with low single-digit error rates, the dollar amounts can be substantial when discussing name-brand medications. There are also ebbs and flows in utilization, and reviewing each period carefully makes sense. It's a move that pays off in the long run.

Claim auditing also achieves fiduciary best practices that are crucial to maintain. Pharmacy plans have a responsibility to pay claims accurately and be able to back up their performance with data. Audit reports provide detailed analysis and proof of accurate payments and best practices followed. There can also be simple things that fall through the cracks, like dispensing name-brand products when generics are available. Granted, it may happen rarely, but when it does spread across thousands of members, it's an error worth questioning, likewise, with any missed discounts or rebates.

When you look for a pharmacy claim auditor, be on the lookout for specialization and experience. Specialist firms with unique expertise have systems and methods that find more errors in less time and for lower costs. They achieve efficiencies because they work in the field daily and have broad experience. Also, as new medications come on the market, others go off-patent, and generics become available, things can change. Your claim payments should respond if it occurs in the middle of a plan year. A first-class auditor will pick up those details, and your plan will benefit.