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Pharmacy Audits & Management Prioritizing Corrective Actions Automatically

We perform retrospective pharmacy claims audits to ensure compliance with PBM contracts, and to serve as benchmarks for future performance. These audits fall under the accounting rules for attestations. We are sensitive to conflicts over audits and make every effort to identify areas requiring validation and to work with all parties to ensure contract compliance.

    Fundamental areas for audit are:
  • Formulary Compliance
  • Eligibility
  • Pricing/MAC Compliance
  • Invalid Claims
  • Excluded Benefits

These audits review invoices along with the pharmacy claims over the desired audit period. These screens also focus on the providers, physicians and pharmacies responsible for rejected claims that did not meet contract requirements, or for which continued monitoring is recommended.

    Pro Pharma’s digital approach to Pharmacy Claims Audits:
  • Are performed on 100% of the pharmacy claims
  • Are fast, efficient and affordable
  • Identifies the outlier physicians and pharmacies
  • Provide supporting information to expedite the process


Retrospective Audit at Work

Problem: A common request these days is -- Can an audit help me to understand why costs are high, as my PBM is not helpful? At the same time other PBMs say they can help, but I am unsure if this is just marketing on their behalf. A client contacted us for an expedited Retrospective Audit to determine the drivers of cost and the options available for change.

Methodology: We performed a Retrospective Audit including tests for eligibility, benefit compliance, brand and generic pricing, specialty pricing/utilization, benchmarking to national and local standards, and transparency in bases of cost. The Audit was expedited through the use of 100% electronic/digital analyses to facilitate quick turn-around time to significantly reduced Audit Costs, and available for desk and mobile devices.

Findings included potential problems with formulary claims that were coded as Brand when the Plan Expected Generics; problems with transparency such that AWP was inflated from national reference databases; specialty approved for total Rx without tests for FDA approvals, quantity, dosage and companion diagnostic tests; pricing above benchmarks, discount generic programs, Medicare/Medicaid when applicable, and patients paying more than cost of drug.

Outcome: The client used the findings to redirect coding options to include only Generic formulary options for multisource (especially timed-release products), OTC, store brands and private labels. They worked with the PBM to correct inflated AWP issues, and variances from Medicare and Medicaid. They moved specialty to Prior Authorization (PA) and improved criteria. They expanded the benefit to include payments for discount generic programs and removed zero-balance options. The result was normative pricing that was measurable and validated, low single digit point-of-sale trends, and a solution for analyzing future spend.

The client felt that they now had control, as they were equipped with a plan, an understanding of the drivers of cost, a solution for matching actual spend to expectations, and improved satisfaction.

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To Learn More:
Phone:(888) 701-5438
info@propharmaconsultants.com