Pharmacy Benefit Auditing
To "manage" and "reconcile" all financial terms, rebates and guarantees in a PBM contract, PBIRx® provides a retrospective and ongoing pharmacy claims audit.
The main objective of our audit is to determine if the Pharmacy Benefit Manager has billed the pharmacy claims in accordance with the language, terms and guarantees outlined in the signed contract. These include discounts based on the Average Wholesale Price (AWP) as recorded by Medi-Span, dispensing fees, administrative fees, etc. Performance, generic and other guarantees including shared savings programs can also be audited as well as auditing of client eligibility for accuracy.
PBIRx® developed our own proprietary prescription claim audit program, AuditRx®. Our experienced staff of actuaries and financial analysts have worked with many PBMs and have been very successful in negotiating recoveries for our clients due to discrepancies in claims billed versus contract language.
The PBIRx® AuditRx® program will give your company the “control” over agreed upon terms stated in the Pharmacy Benefit Manager contract. The data also provides a “predictable” financial and plan design-modeling tool based on the specific drugs that are being dispensed for our Client’s members, versus statistics used by PBM's.
Beyond the obvious opportunity to provide a “cop on the corner” to control the PBM and generate immediate recoveries $$$, the data will provide your company with the ability to integrate reliable information for in-depth analysis of trends, patterns of patient use, physician prescribing patterns and pharmacy dispensing practices.
"Guaranteed Savings" based on contingency or flat dollar fee.
- Facilitate delivery of all PBM claims data in an electronic format to PBIRx®.
- Format financial terms into the AuditRx® Program, which are stated in the signed contract between the Client and the PBM, to provide a pharmacy claims audit.
- Provide auditing results in both summary and detailed formats on the following information:
- Contracted (Pre or Post) AWP discounts, for retail brand/generic; mail brand/generic; specialty brand/generic
- Contracted Dispensing fees and Administrative Fees
- Pass Through Value of Discounts at pharmacies utilized by "your" members
- Generic pricing/guarantee evaluation
- Mac Net Effective Rate
- PBM Shared Savings billing reconciliation
- Rebate reconciliation