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Auditing Pharmacy Claims Catches Errors


Finding another category with as many price variables as prescription medicines would be challenging. Name brands, generics, discounts, and rebates are all factors, and you can quickly see why an Rx audit makes sense for employer-funded plans. With thousands of claims going through the system daily, the chance for errors is obvious. When you add promises for discounts and rebates and the need to check they are credited, it's a multi-faceted system deserving double-checking. Pharmacy benefit managers (PBMs) continually improve their systems, but things can always fall through the cracks.


Auditors who review pharmacy claims know where to look for irregularities, and when they add your plan's formulary to their system, it's specific to your needs. Plan sponsors relying on PBMs to self-report and correct errors have added confidence when auditors take an independent look. Audits are required for regulatory compliance, but checking more often makes financial sense. It also helps with fiduciary responsibility and member service goals. What's notable about claim audits is how they improve the bottom line. It's routine for them to find savings exponentially more than their price.


The improvements in all types of benefits claim auditing, including pharmacy, come thanks to technological advancement. Today's electronic reviews can check for any potential variable with virtually instant answers. It's a revolution compared to the random sampling days where results varied depending on the sample you checked, and the method was ineffective for individual errors that collectively can be worth recovering. You can use your pre-audit meetings to bring up questions relevant to your plan and have auditors check them. The process runs smoothly and requires little of your time.


Although auditors and PBMs maintain cordial relationships, there is a "keeping them honest" dimension to the auditor's work. They are the last line of defense for plan sponsors against costly errors. It can be as simple as name-brand medications being dispensed when generics are available. Or uncredited rebates that are buried deep in unanalyzed claim data. It also makes a case for using specialist auditors who know the ins and outs of pharmacy claims. The more focused their systems are, the better they flag irregularities. The audit firm's expertise works to your plan's advantage.

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