Rx Plans Also Need Claim Audits

Posted on 9 October, 2023 by TFGPartners

Every type of benefit plan warrants oversight, and running an Rx audit is always a good idea. No matter how accurately your pharmacy benefits manager (PBM) processes claims, some things can fall through the cracks – or you don't receive the owed rebates and discounts. Either way, professional auditors closely examining claims will show what is happening. Even name-brand products being dispensed when generics are available can be an issue, as apparent as it should be to dispensers. The numbers are high with the cost of medicines, and only factual data like an audit report flags errors. 

Many large employers that sponsor their benefit plans audit their prescription claims around the same time they review their medical plans. It's a wise idea from a cost management standpoint and keeps you abreast of trends that may not be coming through in reports from your PBM. Oversight also affects claim administrators, who may self-police more closely if they know you're reviewing their work. Even error rates in the low single digits can be material sums for more extensive plans with millions in expenses. It's also easier to be reimbursed for overpayments and mistakes soon after they occur. 

The medical plan audits that run alongside Rx audits need a different approach but one that's equally detailed. Medical billing and coding knowledge is essential, which is why specialty audit firms produce the best results. Their people review claims every day, and many have prior experience at large health carriers handling claims. More powerful software and systems have greatly expanded what electronic reviews can produce. They bring down costs and improve accuracy because what they catch with the correct setup is impressive. It can include your plan's unique provisions in greater detail. 

When switching to a new PBM, schedule an implementation audit after three months. An auditor's independent assessment of system setup and initial processing accuracy is eye-opening. Comparing their assessment against self-reporting from your PBM also helps establish a baseline of accuracy. There's also value in using the same audit firm consistently. They become more familiar with your plan's intricacies each time, and you can compare their current and past reports. Today, it's possible to audit plan performance more closely, and it's excellent for plan management.

Company Name- TFG Partners, LLC

Address- 437 Grant St #1020, Pittsburgh, PA 15219

Contact Number- (412)-281-2228