PSG - Pharmaceutical Strategies Group

Contract/Financial/Plan Compliance Review (Audit)

PSG’s clients are interested in knowing whether their PBM is measuring up to the financial terms of their contract and administering their plan design accurately. Our data and reporting team has built a robust verification tool to ensure that PBM pricing protocols and plan design are adjudicating in strict accordance with the contract.  The accurate interpretation of contract terms by an experienced PSG underwriter, coupled with a detailed claim-by-claim analysis of historical client utilization data, forms the basis of our compliance report.   The result of the compliance analysis is a compliance report that demonstrates whether the PBM has lived up to the financial terms of the agreement and is correctly applying the client’s plan design while identifying any potential sources of variance.

Under our proprietary contract compliance review process, PSG rigorously monitors key PBM operational and pricing performance criteria. 

Process

1. Load claims data in data warehouse.
2. Load appropriate pricing and plan design parameters according to client agreement.
3. Validate accuracy of program pricing elements and copays by distribution channel.
   1. Retail.
   2. Mail.
   3. Specialty.
4. Produce summary report that identifies the source and extent of any pricing variances.
5. Validate accuracy of plan design elements (e.g., copayments including coinsurance, flat copays, minimums and maximums).
6. In addition to validating program pricing elements, PSG also assists in monitoring other important elements of pharmacy programs including PBM performance against operational guarantees.

PSG works with each client to develop a custom timeline for the auditing process depending on the size and scope of the project.