Annual Pharmaceutical Audit Uncovers Systemic Errors

Business Situation

This large county government engages BMI to conduct annual pharmaceutical claims audits of their self-insured pharmaceutical plan and pharmacy benefit manager (PBM).  In addition, the client also engaged BMI to conduct a contractual financial guarantee audit.

Solution

BMI performed 2 full-service pharmaceutical drug audits which evaluated areas such as:

  • Plan Compliance – member / plan cost share, excluded / limited drugs, prior-authorization, days supply, step-therapy, and others.

  • Fraud/Waste/Abuse – duplicate scripts, refill too soon, provider profiling issues, abuse and addictive agents, and others.

  • Eligibility – claims paid when member was not eligible, no eligibility

Audit Findings

  • Quantity limits not applied correctly

  • Refills without appropriate prior authorization

  • Deductibles not considered while calculating member liability

  • Identification of drug “spread” pricing practices and recommendations on key contractual changes

Audit Outcome

The PBM agreed to initial overpayment amounts exceeding $13,000 and committed to providing an impact assessment and remediation plan to identify all impacted claims which BMI estimated to be an additional $36,000. Contractual language changes were taken under consideration ahead of renewal.

At the conclusion of the audit, BMI assigned a specialist to walk through a variety of additional recommendations and solutions to resolve and prevent future claims processing errors from occurring.

Contact us to learn more about our solutions.

Audit Finding of the M..., pharmacy benefits manager, pbm, prescription drug clai..., payment errors, health care claims, health care benefits a..., financial guarantee audit, BMI Audit Services, audit samples, AUDiT iQRobert Temples