As a plan administrator, you know an audit is the best way to reveal weaknesses and inconsistencies in your benefit plan. After all, PBMs process millions of claims per year and with that kind of volume, unintentional errors can, and do, occur. In fact, when auditing the pricing guarantees from our client’s PBM contracts, we find TWO-THIRDS ARE NOT PERFORMING to the level stated in the contract.
Our reporting team has built a robust proprietary auditing and financial verification tool that ensures PBM pricing protocols and plan design parameters are adjudicating in strict accordance with the contract and plan documents. The accurate interpretation of contract terms by an experienced PSG underwriter, coupled with a detailed claim-by-claim analysis of historical utilization data, forms the basis of our audit report.
Benefit: Plan Design Audit — review of claims to verify that benefits have been appropriately applied for the benefit designs and formularies offered under the plan
Clinical Audit — review of drug use patterns, claims and clinical management, including drug quantity limits, therapy duration limits, prior authorizations and step therapy protocols
Pricing Guarantee Audit — review of claims to verify that the pricing protocols and financial guarantees applied by the PBM are compliant with the terms of the contract
Implementation Audit — pre-and post-implementation audits identify that plan design parameters are accurate and designed to accomplish the objectives set forth by the plan sponsor
Rebate Audit — determines with reason able assurance that the rebates paid to the client are compliant with manufacturer agreements
Fraud, Waste & Abuse (FWA) — provides ongoing oversight, identifies outliers and trends, validates appropriateness of drug usage, and provides follow-up analysis
The result of the compliance analysis is a report that demonstrates whether the PBM has lived up to the financial terms of the agreement and is correctly applying your plan design while identifying any potential sources of variance.
Client needs vary, so PSG offers a choice of audits capable of impacting both financial and clinical returns.Choose from a single audit or a combination that works best for you.