It’s never been a better time to audit your Pharmacy Benefit Manager (PBM) and the claim payments it makes on your plan’s behalf. With drug price increases expected in 2023 for commercial and employer-sponsored health plans, keeping an eye on things will be vital. The Inflation Reduction Act’s requirement that Medicare negotiates lower prices for some top-selling medicines is likely to bring cost shifting with price increases for private payers. It will be big pharma’s way of recouping lost revenue.
Prescription claim auditing has long made good financial and plan management sense, given the highly complex drug pricing landscape with rebates, discounts, spread pricing, etc. The industry is known for stories about PBM’s pocketing rebates to increase profitability while having plans to pay the full, un-rebated price for medicines. As prices go up for private payers after the Medicare negotiations, the value of an analytical look at what you’re paying and how it may have increased will be crucial.
TFG Audits and Monitoring Bring Fast and Significant Results
Example #1: Hospital System Client. A TFG Rx Plan Audit Helped Correct System Set-Up Errors and PBM System Errors. The result was Immediate Cost Savings, Recoveries, and Bottom-Line Improvements.
Example #2: Large Health Care Services Provider. TFG’s Continuous Monitoring Services Detected Large Missed Discounts Leading Meaningful Recoveries Based on Concrete Data.
How Can Pharmacy Claim Auditing Help Your Plan?
Auditing pharmacy claims is one of the most effective ways to ensure PBMs keep their promises. Most guarantee they will optimize plan efficiency and contain costs when promoting their services. But are they doing it well? Independent auditors can give you a detailed answer to the question, and you’ll be in a stronger oversight position with a factual report in hand. It’s in every plan sponsor’s interest to have access to data and be in charge of it. If anything in your PBM agreement or working relationship reduces your access, it’s something to change – you need to see and understand pricing data.
TFG is a Leader in Pharmacy Claim Auditing, and We Pioneer the Industry’s Best Practices
Our TFG pharmacy claim audits give you an unbiased third-party analysis of your data and identify opportunities. Knowing where the highest costs are coming from and ways to mitigate them is helpful. You can also save by optimizing utilization. Our industry-leading capabilities include advice on where you can require lower-priced medicines to replace expensive ones and have the same patient outcomes. The right knowledge means everything and independent audit firms like ours have no allegiances other than to help you plan serve members well and contain costs.
Consider Monitoring Your Prescription Plan Continuously
One of the best ways to manage your prescription plan and conduct oversight of your PBM is to monitor your claim payment continuously. The price increase environment expected during 2023 makes it one of the best times to consider adding the service. With our Continuous Monitoring Services, we can keep audit software running unobtrusively in the background and report to you monthly. Monitoring continuously lets us immediately catch irregularities, such as suddenly skyrocketing prices for a specific medicine. You’ll have fewer surprises and problems, and your plan will be better managed based on data.
Auditing or monitoring your pharmacy benefit plan is also a budget-friendly decision. The price for the service is often as little as one-fourth of the savings you’ll realize. Large corporate and nonprofit employers that sponsor plans have everything to gain and nothing to lose from PBM oversight. When you add in the expected price increases in 2023, it’s the ideal moment to find out more. Our TFG audits review 100 percent pharmacy benefit claims for unprecedented accuracy and require very little of your time. If you’re ready to prepare for the coming year, we’re pleased to explain more about our services. Contact us today.