The Wisdom of Auditing Rx Claims

Much is written and said about the complexity of medical billing, but medicines aren't far behind. For large employers sponsoring benefit plans, running an Rx audit at the same time medical claims are reviewed makes excellent sense. Pharmacy benefit managers (PBMs) are turning in impressive performance statistics today and driving error rates ultra-low. However, many dimensions, including discounts and rebates, make oversight and an independent review of claim payments worthwhile. Things change during plan years; sometimes, even the best claim administrators miss an update.

Pharmacy claim audits can also go after basic errors such as dispensing high-price name-brand products when lower-cost generics are available. When today's audits review 100 percent of claims, individual errors are flagged along with repeating mistakes that affect larger member groups. Recovery is up to you as the plan's sponsor, and auditors give you the factual data to decide which to pursue. Claim audits satisfy regulatory and compliance requirements but become much more valuable as management tools. Any mistakes are detected earlier when you audit soon after claims are paid.

The audit setup meetings are when plan sponsors can set goals for the review. Auditors working daily in the field know where to look for routine errors. But if you add questions to the audit based on your plan's unique experience and provisions, the data will be of higher quality. It's also enlightening to compare years if you work with the same auditor and have reports that line up. If you've been in plan management for several years, you may have learned that surprises nearly always occur. The sooner an auditor brings them to your attention, the better your chance of keeping them contained.

If your PBM has performance guarantees built into its service agreement, auditors can confirm whether the promises are being met. If not, you'll have a date-rich report in hand when you question performance and accuracy. If providers make errors and you catch and recover them, they'll likely handle your plan's future claims more carefully. It's human nature to work more cautiously when you know there is oversight. There's also heightened scrutiny on fiduciary best practices for employee benefit plans and audits, which help keep you on track – and you can quickly correct any error patterns.