RECURRING PHARMACY CLAIMS AUDIT CONTINUES TO DELIVER RESULTS FOR PLAN SPONSORS

Business Situation

For over a decade, a large public school district has partnered with BMI Audit Services to conduct annual pharmacy claims audits of its prescription drug plans and Pharmacy Benefit Manager (PBM). This ongoing relationship highlights the value of routine audits in identifying errors, improving compliance, and recovering costs. 

Solution

Leveraging our experienced audit team and proprietary AUDiT iQ™ software, BMI established key objectives to guide each annual Rx claims audit: 

  • Analyze 100% of prescription drug claims paid by the PBM over a 12-month period 

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

  • Audit a targeted sample of claims based on findings from the full data review 

  • Present detailed results along with specific cost-savings recommendations and next steps 

Audit Findings

Several issues were uncovered during the most recent audit, including: 

  • An 87-day supply of a drug refilled after only 51 days 

  • Prescriptions filled after a member’s plan termination 

  • Discrepancies in prior authorization records between the PBM and plan documentation 

Audit Outcome

The PBM acknowledged overpayments totaling nearly $24,000, citing incorrect plan programming as the cause of many discrepancies. These findings reinforced the importance of regular oversight and led to further improvements in how the PBM aligns system settings with plan design. 

To close the audit, BMI assigned a dedicated specialist to walk through both short-term corrections and long-term improvements aimed at preventing similar issues from recurring. 

Pharmacy Claims Audit, Healthcare Claims AuditRobert Temples