Pharmaceutical Audit Uncovers $500K in PBM Errors: Why Healthcare Audits Matter for Employers

Rising prescription drug costs and complex pharmacy benefit manager (PBM) agreements make it critical to verify the accuracy of their healthcare claims. A pharmaceutical audit provides a review of pharmacy insurance claims data to check for errors and make sure claims are paid correctly by the pharmacy benefit manager (PBM) . 

Business Situation 

A major metropolitan hospital engaged BMI to conduct a pharmaceutical audit of its prescription drug plan and PBM to ensure claims were being processed accurately and in compliance with plan rules. With rising costs and fiduciary responsibilities, the hospital sought independent validation of PBM performance and a safeguard against costly errors in its healthcare benefits program. 

Solution 

Using our experienced healthcare audit team and proprietary AUDiT iQ™ software, BMI developed a tailored pharmaceutical audit plan with the following objectives: 

  • Analyze 100% of prescription drug claims paid by the PBM over a 24-month period. 

  • Test claims for compliance, eligibility, and potential fraud, waste, or abuse. 

  • Audit a targeted sample of claims based on data analysis to validate systemic issues. 

  • Present findings with actionable cost-savings recommendations for both short- and long-term impact. 

This comprehensive methodology ensured no claims were overlooked and gave the hospital a clear picture of how its pharmacy plan was being managed. 

Audit Findings 

BMI’s pharmaceutical audit uncovered multiple areas of concern, including: 

  • Fertility medications being covered beyond the maximum benefit limit of $15,000. 

  • High-cost specialty drugs exceeding $10,000 that were dispensed without prior authorization. 

These findings highlighted not only compliance gaps but also serious fiduciary risks for the hospital and its plan sponsors. 

Audit Outcome 

The PBM initially acknowledged overpayment amounts of $19,500, citing incorrect coding as the root cause of many discrepancies. Analysis uncovered additional claims totaling over $500,000 in errors related to similar issues. 

To address these findings, the PBM agreed to conduct impact studies to measure the overall financial implications for the hospital’s healthcare plan. 

Conclusion 

This case study illustrates the critical value of a pharmaceutical audit and broader healthcare claims audits in uncovering errors, ensuring compliance, and protecting employer healthcare dollars. For brokers and plan sponsors, audits not only identify direct cost savings but also strengthen fiduciary oversight of PBMs. With prescription drug costs continuing to rise, proactive auditing provides a proven strategy to safeguard plan integrity and recover significant dollars, just as this audit revealed more than $500,000 in errors. 

Pharmacy Claims Audit, Healthcare Claims AuditRobert Temples