Rx Claim Audits’ Value Increases in a Changing PBM Landscape

Pharmacy Claim Auditing Matters Now More Than Ever

Higher prescription costs and the need to reduce them are driving shake-ups in the PBM landscape. Today, we see an increasing number of health plans changing or questioning their pharmacy benefit managers (PBMs). In every case, there is a vital role to play in a thorough Request for Proposal (RFP)  evaluation and negotiation, followed by Rx claim auditing and continuous monitoring.

Blue Shield of California recently made news by abandoning long-established PBMs in favor of different “disrupter” companies, giving them access to much better deals on pricing and sensible formulary and clinical management. In other examples, it’s about self-funded plans (and health care consumers) rising up against carriers owning retail mail and specialty pharmacies that set higher prices.

Claim Reviews Can Validate Cost Savings Promises

Claim auditors are scorekeepers who help ensure complex financial transactions are correct, and you capture savings no matter how they come. You can request audit reports be structured to contain any data you need to double-check against the relevant variables. Audits strictly validate the delivery of all contractual promises and hard-negotiated commitments:

• Lower prices
• Discounts
• Rebates
• Overall savings guarantees

If you’re considering switching your plan to new sources for medication purchases, putting out RFPs tied to validation through audits is the way to go. As the recent news confirms, you can’t take things for granted, and adding audit-based validation to your agreements makes more sense than ever.

 

Prescription Claims Auditing with Two Options

Our pharmacy claim auditors can work retrospectively in the traditional model, or you can go for the trending option of continuous monitoring. Either produces excellent results, but working in near real-time with Continuous Monitoring Service has worthwhile advantages ranging from eliminating missed rebates or discounts to better control over your cash flow, all delivering a positive ROI — not to mention the elimination of cumbersome retrospective audit efforts and subsequent haggling over refunds.

• Option #1: Claim audits for a retroactive review
• Option #2: Continuous claim monitoring and reporting

The near real-time tracking and accountability you have when monitoring continuously allows you to manage your plan more actively. When we flag concerns in their earliest stages, correcting them is more manageable and can prevent hundreds of thousands of dollars in problems.

It works similarly to the consumer axiom about being a “smart shopper,” always knowing what you’re paying and having the information to confirm whether you’re receiving the lowest price.

How are Today’s Audits More Powerful?

When you work with us for pharmacy or medical claim auditing, we’ll review 100 percent of your claims. Using powerful, proprietary systems and our deep knowledge of PBM “best practices,” we’ll provide you with a highly accurate and insightful report about your plan’s performance — from benefit compliance that assures your members get what their plans promise to in-depth financial validation against contractual terms.

At TFG Partners, we pioneered the 100 percent method and brought the industry forward from random sampling. Ever since we’ve never looked back and have improved our claim audit systems and capabilities every year – and our clients benefit from every improvement.

Conclusion: Depend on Our Audits for Pharmacy Plans

If you decide to switch your plan’s prescription arrangements to one of the newer money-saving options, remember to build in the oversight from the start.

Your RFPs can include clear stipulations to assure effective, meaningful audit rights and even require credits to pay for audits. The proper terms let you, as opposed to the to-be-audited party, decide how and with what frequency we audit your pharmacy claims.

Sign up for the more sophisticated Continuous Monitoring Service, and you can receive reports in near real-time and keep everybody on track with a well-performing, efficient prescription plan.

Cost-containment (or reduction) for your pharmacy plan is a significant opportunity. Make sure you enter an agreement that works in your favor – and let us audit pharmacy claims to independently confirm you’re receiving everything you are promised.

If you have questions or would like more information

about our complete range of benefit plan auditing services, reach out today.