The costs of providing prescription drug coverage continue to rise making claims audits increasingly popular in recent years. Organizations often decide to conduct prescription drug claims audits and medical claims audits at the same time to maximize opportunities for cost savings.
Compared to medical claims audits, these audits often take less time to complete and usually don’t require an onsite examination at the third-party administrator’s claim payment facility. Similar to medical claims audits, plan documentation is received, claims data is analyzed and samples are selected.
Depending on the audit firm, audit approach, and technology used, prescription drug claims audits can uncover a wide variety of claims adjudication issues and/or weaknesses in areas such as exclusions or limitations, prior authorizations, copays, dispensing fees, discounts or rebates.
You can read more about our prescription drug claims audits on our blog.