Pharmaceutical Audits Yield Significant Cost Recovery

Business Situation 

This public school district engaged BMI to conduct a pharmaceutical claims audit of their self-insured pharmaceutical plans and pharmacy benefit manager (PBM).  In addition, the client also engaged BMI to conduct an on-site rebate audit, as well as a complete contractual financial guarantee audit.

Solution

BMI performed three full-service pharmaceutical drug audits which included:

  • 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 not eligible, no eligibility.

  • Contractual Financial Guarantee Audit: AWP discounts, dispensing fees, and other consultative recommendations.

  • On-site Rebate Audit

  Audit Findings

  • Financial guarantee AWP discount calculation error, in a retail setting:

    • $780,000 recovered

  • Health Care Reform compliance errors with respect to contraceptive drugs:

    • $210,000 recovered

  • Rebate payment errors:

    • $45,000 recovered

  • Prior-authorization not performed correctly:

    • $25,000 recovered

Audit Outcome

As a result of the above audit findings, BMI identified over $1,060,000 in payment errors that were successfully recovered back to the client. Learn more about pharmaceutical claims audits here.

ASO, Audit Finding of the M..., claims administrator, financial guarantee audit, health care benefits a..., health care claims, health plan audit, on-site rebate audit, payment errors, pbm, pharmacy benefits manager, prescription drug clai..., prior authorization, Third-Party Administrator, TPA auditRob Temples