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Pharmacy Audits

Our services provide measurable outcomes that benefit our clients. If your PBM is not performing up to contractual obligations, we will uncover the financial impact to your organization, resolve the situation and determine money that's owed back to you. 
Solutions based on 100% data review-communicated in a user-friendly format for easy decision support- give you all the information you need for process improvement, quality assurance and actuarially sound modeling.
We'll help you discover, analyze, and define your program's opprotunites and risks  
Three Phase Audit Process

Phase One

  • Contract Assessment

Contract assessment begins with a thorough review of your current PBM contract. Upon analysis, we will determine if your PBM is performing to agreed-upon contract terms

Phase Two

  • Claims Data
    We load 1 year of claims data to identify:
  1. NDC- No definition
  2. Pharmacies - No definition
  3. Brand/Generic found in the claims vs Brand/Generic in Medi-Span
  4. AWP in claims data vs AWP published in Medi-SPAN
  5. Elegibility 
 

Phase Three

  • Quantitative Comparison
To make a sound financial comparison of your current PBM's performance, we compare the contract rates with the loaded claims data, which include:
  • Brand Pricing
  • Overall Generic Pricing
  • Specialty Pricing 
  • Mail Order
  • Narrow and Broad retail networks
  • Rebates
  • Dispensing fees
  • Member Cost Share Analysis (copays)
 

Auditing 

  • Plan Design

  • Pricing 

  • Rebate

       Desktop Rebate

       Onsite Rebate

  • Fraud waste & abuse (FWA)

       FWA filters and queries

       Member identification

  • Rejected Claims Analysis 

       CMS expectations 

       Complete Transition patient analysis 

       End to end compliance

 

  • Medicare Eligibility Accuracy

 

  • Medicare Prescription Drug Event (PDE)

 

  • Pharmacy Network Contract

 

  • Adherence

 

  • Delegated Services

       Pharmacy & member call center

       Grievances & appeals

  • Eligibility

Helping our clients manage pharmaceutical expenditures and utilization 

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