Prescription Drug Payment Errors Prove Costly Following Audit
Audit Issue
Client plan language indicated 1) an age edit rule for acne medication, 2) an exclusion for fertility drugs and 3) a prior-authorization requirement on several drugs.
Audit Finding
Using our proprietary software AUDiT iQ™, we identified paid claims for acne medication where the members had exceeded the minimum age required to receive the drug. In addition, paid claims were also identified for fertility drugs and for drugs where a prior-authorization was required but was not done.
Third-Party Administrator Response
The claims administrator acknowledged that their system had not been properly configured for the acne drug age edit. They also acknowledged that an appropriate rule was not in place to exclude fertility drugs and that a prior-authorization rule was not in place for the drug Lamisil.
Financial Error
The administrator agreed to financial errors exceeding $23,000.00.
Explore All Blog Categories
- ASO
- AUDiT iQ
- Affordable Care Act
- Audit Finding of the M...
- BMI Audit Services
- CPT code
- Dependent Eligibility ...
- ERISA
- Ineligible Dependent A...
- Medical Claims Audits
- Sarbanes-Oxley
- Self-Insurance Programs
- Smart Business
- Spousal surcharge audit
- TPA audit
- Third-Party Administrator
- Uncategorized
- Value Forward
- audit samples
- claim audit
- claims administrator
- claims audit
- claims data
- cost-containment solution
- dependent audit
- dependent verification...
- drug exclusion
- duplicate payments
- durable medical equpment
- eligibility
- eligible dependent
- enrollment
- financial guarantee audit
- health care benefits a...
- health care claims
- health plan audit
- internal audit department
- medical and prescripti...
- on-site rebate audit
- ongoing dependent elig...
- payment errors
- pbm
- pharmacy benefits manager
- plan eligibility
- pre-implementation audit
- prescription drug clai...
- prior authorization
- re-enrollment audit
- retrospective audit
- routine pregnancy