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Skyrocketing Drug Prices Demand Scrutiny

Anyone involved in paying for prescription medicines knows the prices can be shocking. Therefore, you can imagine the impact on employer-funded health plans paying on behalf of members. In the current environment, running an Rx audit routinely makes excellent sense. New medicines come on the market yearly as others go off-patent and become available as generics. While everyone can program their systems to recognize the dates and prices, it’s a system rife with details, and errors can happen. Discounts and rebates are also in the mix as manufacturers compete for your plan’s business.

When credits are due after specified purchases, are they correctly paid back? One way to be sure is to have an auditor double-check your claims and payments and then check the rebated amounts. In many cases, they’ll be correct, but for those who aren’t catching them and requesting reimbursement, it is fair and keeps your plan on track budget. It’s also likely that all parties involved will become more careful once you begin running oversight. You’ll likely see a long-term improvement as all parties understand you’re reviewing their work for accuracy and are more cautious with your claims.

Switching to a new pharmacy benefit manager (PBM) also demands an independent implementation audit. For many years, the primary emphasis was on medical claims, but it’s been expanded to a healthcare purview, which now includes Rx. There are many variables when thousands of claims are processed weekly, and the audit service more than pays for itself. It’s common for claim auditing to produce recoverable savings four times the audit price. Few services you can hire are revenue-positive, but claim reviews are one. They’re also a valuable part of implementing fiduciary best practices.

Benefit plan performance can be measured in multiple ways, but few things match claim payment accuracy in importance. It goes directly to costs and member service. While the formularies of prescription plans may make things appear cut and dried, there are still issues that affect performance. They can be simple things such as dispensing name-brand products when generics are offered to more complex and nuanced errors. Auditors give you a clear snapshot of your plan’s claim payments and make managing it more precise. Otherwise, you’re left with little more than your PBM’s self-reporting.


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