PBM’s System Not Correctly Programmed: Approvals Given Despite No Prior Authorization

Audit Issue

We reviewed prescription drug plan claims data provided for any potential systemic error issues regarding exclusions, drugs requiring prior authorizations, limitations, etc.


Audit Finding

Though the plan excluded drugs or supplies used for the treatment of erectile dysfunction, impotence or sexual dysfunction or inadequacy, multiple drugs used to treat erectile dysfunction were authorized for payment. In addition, our auditors confirmed that prior authorization was not on file to indicate a review even occurred for medical necessity and plan exclusion language.  In addition to the samples selected for audit, BMI’s system also flagged 123 additional claims totaling more than $50,000 for the same payment issues.

Prescription Benefits Manager Response

The administrator agreed to the error stating their system was not programmed correctly for the drugs requiring prior authorization.

Financial Error

The administrator agreed to errors in the amount of $9,783 and to run impact reports to determine whether the additional 123 claims flagged would be affected by the drug exclusion errors.

Audit Finding of the M..., BMI Audit Services, drug exclusion, health care claims, pharmacy benefits manager, prescription drug clai..., prior authorizationRandy Light, Founder + Executive Advisor