Pharmacy Benefit Auditors will review 100% of pharmacy claims processed by the Pharmacy Benefit Manager (PBM) to determine the accuracy of the claims processing as compared to the agreed upon benefit design.  Some of the components of the PBM audit are:

  • Contract Analysis

  • Average Wholesale Price Validation

  • Generic Drug Pricing

  • Lessor of Usual and Customary (U&C)

  • Dispensing Fee

  • Day's Supply

  • National Drug Code(NDC) Accuracy

  • Rebates

  • Over the Counter (OTC) Medications

  • Specialty Drugs

  • Mail Order Performance

  • Fraud and Abuse

  • Invoice Reconciliation


Areas in which we find significant contract noncompliance are as follows:

  • Generic and Brand discounts applied incorrectly

  • Lesser of U&C, MAC, or AWP Pricing not followed

  • Dispensing Fees incorrectly charged

  • Incorrect Copayments collected

  • Terminated Members receiving Prescriptions

  • Spread Pricing

  • Rebates Incorrectly Calculated and Paid

  • Days’ Supply Parameters not being followed

  • Excluded Drugs being Covered

  • Invalid NDCs being Covered

  • Zero-balance Copayments being charged

  • Reversals not Credited

  • Deductibles and Accumulators not being calculated correctly

  • Plan’s Generic Drug Policies not being followed correctly

  • Paper Claims Submitted by members not processed correctly

  • Prior Authorization’s and Exceptions to Plan Design not Documented

  • Timely Submission and Filing of Claims not followed correctly

  • High Dollar Claim limits being exceeded

  • Fraud and Abuse

  • Sales taxes charged to the plan sponsor

  • Metric decimal quantities rounded in favor of the PBM and much more....................




PHARMACY BENEFIT MANAGER AUDIT SERVICES

Pharmacy Benefit Auditors