Rx Plan Audits

Each year, your self-insured health plan pays for thousands of prescription drug claims, which, in many cases, represents millions of dollars. Yet without an independent pharmacy plan audit, how do you now if you’re being billed correctly by your Pharmacy Benefits Manager (PBM)? Quite frankly, you don’t.

The moment you suspect incorrect billing, improper prescription drug use, medication errors, incorrect discounts, incorrect dispensing fees, you should call HDM. We find these problems in prescription drug plans all the time for some of the biggest companies in America. HDM’s Prescription Drug Plan Audit reviews drug claims and identifies misuse, overuse, fraud and errors.

Self-insured employers need assurance that Pharmacy Benefit Managers are paying prescription drug claims accurately and appropriately according to formulary and terms of the Administrative Service Only (ASO) agreement. To achieve this goal, HDM conducts a comprehensive review of PBMs, including a 100-percent-of-claims audit and rebate audit to…

• Determine compliance with both contract terms and plan documents.
• Assess financial accuracy of paid claims and administrative processes, including claims error and fraud detection.
• Evaluate accuracy of payments and identify overpayments.
• Identify control weaknesses, their causes and suggest process enhancement/cost savings prospects.
• Assess retail and mail order programs.
• Review our client's role regarding administration, and offer recommendations.
• Identify, validate, and recover overpayments.

The following services can be included in a prescription drug plan audit:

Claims Audit
HDM analyzes 100% of prescription drug claims paid during the audit period, including retail and mail order programs. We do not base our findings on samples.

Onsite Audits at PBMs
HDM auditors visit our client’s PBM(s) to review the control environment and claims analysis and perform a rebate audit. Our auditors evaluate the effectiveness of PBM policies and procedures in the administration of your prescription drug program.

Rebate Audit
A rebate audit is conducted to determine the accuracy of rebate payments from the PBM to our clients. HDM will reconcile payments with claims data to ensure that the correct amount of money was paid to our client by matching dollars paid to PBM within manufacturer contracts and formulary requirements.

Financial Reconciliation
HDM performs a financial and funding reconciliation, utilizing PBM reports and client banking records. We review adequacy of the funding requests and reconcile all funding and payment bank records, thus assuring there are adequate controls over financial transactions.

Recovery of Overpayments
HDM presents validated claim errors and overpayments to the administrator for recovery, and negotiates and monitors recovery collection activity to ensure recovered dollars go back to you, our client.

To discuss how HDM’s cost containment solutions for self-insured employers can benefit your organization, contact HDM today at 800.859.5119 ext. 1 or e-mail your inquiry to: info@HDMinc.com.