The pricing model for pharmaceuticals covered by employer-sponsored health plans frequently incorporates rebates and discounts, which can either be deducted from the total cost at the point of sale or credited back. However, tracking them across numerous transactions can be challenging, making Rx and medical claim auditing services beneficial. Audit teams utilize advanced systems to evaluate thousands of transactions and report their findings. Even with the technologies employed by pharmacy benefit managers (PBMs), some discrepancies may still occur, and these differences can be substantial.
Adhering to fiduciary best practices across all facets of health plans is essential. It entails accurately processing claims and ensuring that expected discounts and rebates are received. Audit oversight plays a crucial role in this process. Nowadays, it’s common to conduct regular audits or to have claims reviewed on a monthly basis. Key metrics can be integrated into these procedures to monitor various factors, as numerous potential irregularities can arise in medication payments. While formularies appear straightforward, incorporating discounts and rebates complicates matters.
Mistakes, such as dispensing name-brand medications when generics are available, can occur more frequently than one might expect. It is especially true when a medication first becomes available in a generic form. Such learning curves can be costly for plan sponsors, and audit data can serve as a crucial reminder for those who may be slow to adapt. Although PBMs might be held accountable for these performance guarantees, errors can go unaddressed unless they are identified and reported. Regular oversight also encourages providers to maintain high standards, as monitoring promotes caution.
An effective healthcare auditing system should also encompass medical claims, as these and pharmacy plans represent the most significant expenses in employee benefits. There can be inconsistencies in situations where large employers delegate claim administration, given that one company is processing payments for another. When claim administration is outsourced, audits become even more essential to double-check. If you are in the process of negotiating new agreements with providers, it’s crucial to ensure there are no restrictions regarding the frequency and type of audits you can perform.
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