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The Discounts and Rebates of Rx Claims

The pricing structure for the pharmaceuticals paid for by employer-sponsored health plans often includes rebates and discounts. They can be deducted from the prices paid or credited later. In either case, tracking them across thousands of transactions is challenging, and an Rx audit can help. With their sophisticated systems, claim auditors can review thousands of transactions for accuracy and report on their findings. Even when pharmacy benefit managers (PBMs) have sophisticated systems, something may fall through the cracks. Given the price of medicines today, the numbers can be significant. 


With fiduciary best practices for all health plan aspects, making news, paying claims accurately, and receiving promised discounts and rebates matter more than ever. The added oversight that audits provide is an integral part of the process. It's increasingly common to audit routinely or have claims reviewed monthly. You can build key metrics into the process and check for many variables. There is no shortage of potential irregularities that can occur with medication payments. Formularies make them appear simple, but adding discounts and rebates becomes significantly more complex. 


Even basic errors like dispensing name-brand products when generics are available can happen more often than you think. It happens most commonly when a medication first becomes available generically, and the marketplace adjusts. The learning curve can be costly to plan sponsors, and audit data can help remind those who are slow to realize. When PBMs make performance guarantees, they may be liable for those errors, but they may go unnoticed unless you catch and report them. Routine oversight also helps providers do their best. Human nature is to be more cautious when it's clear someone is watching. 


A sound healthcare auditing system also considers medical claims. When combined with pharmacy plans, they are the most significant dollar items in employee benefits. When large employers sponsor programs but outsource claim administration, you have the no-standard process of one company paying another one's bills. When claim processing is out of house, oversight like audits provide figures more prominently into the equation. If you're negotiating new provider agreements, ensure there are no limits on the frequency and type of auditing you're allowed to conduct. It matters in the long run. 

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