Pharmacy Benefit Manager's Claims Payment Errors Corrected

Audit Issue

With an average of a half of a million dollars spent per month on prescription drug benefits, our client engaged us to conduct an audit of their pharmacy benefit manager to include extensive examinations of plan parameters such as:

  • Excluded and/or Limited Drug Types

  • Prior Authorizations

  • Copays

  • Coordination of Benefits

  • Dispensing fees

  • AWP/MAC Discounts

  • Rebate Guarantees

Audit Finding

Three (3) audit samples with 42 additional related claim payments for the same patient or same type of error were identified in the data for prescriptions of opiate addiction and pain killers. Our auditors confirmed that these claims were adjudicated without prior authorization on file.

Throughout the investigation, it was also discovered that certain members, despite a 30-day supply limit, had been refilling every 10-15 days for a total of over a 100 day supply on hand when the prescription was filled.


PBM/Administrator Response

The administrator agreed to the errors presented and issued a credit to the client’s account for the amount of claim payment errors.  In addition, the administrator acknowledged additional edit rules needed to be completed to their system to correct the plan set up to prevent future adjudication errors.

Financial Error

The administrator agreed to errors in the amount of more than $40,000 and to make significant improvements in their adjudication systems.

claim audit, claims audit, Medical Claims Audits, pharmacy benefits manager, prescription drug clai...Randy Light, Founder + Executive Advisor