Pharmacy Benefit Auditing at PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

Since pharmacy costs represent nearly 40% of today's total health care costs, it is crucial for any entity that provides pharmacy benefits to its employees or members to audit all the financial discounts and guarantees stated in their PBM contract to be sure that claims are being adjudicated exactly as you agreed to in your PBM negotiations. 

Furthermore, as the cost and utilization of specialty drugs continues to rise, it is even more important to make sure that the discounts negotiated are in accordance with the terms outlined in the signed contract including Limited Distribution Specialty Drugs and new drugs that come to market. 

At PBIRx, it is our goal to make sure that the language, discounts and guarantees stated in our clients' contracts are being adjudicated accurately by the PBM, which is why we provide comprehensive pharmacy claims audits using our proprietary AuditRx® platform.

AuditRx® presents our clients with a comprehensive written report with Exhibits to provide to the PBM. Additionally, our team of experienced actuaries and financial analysts have been very successful in negotiations with various PBMs resulting in significant monetary recoveries.

The following is a brief description of the AuditRx® process, which can be annually, quarterly or monthly:

• Facilitate delivery of all PBM claims data in an electronic format to PBIRx.
• Format financial terms which are stated in the signed contract between the client and the PBM, into the AuditRx® platform.
• Provide auditing results in both summary and detailed formats on the accuracy of information such as contracted brand/generic discounts, dispensing fees for retail, mail and specialty pharmacy along with administrative fees.
• Review contract language related to PBM shared savings billing reconciliation and member co-payments in accordance with plan design and claims paid by ineligible members.
• Provide eligibility audit to be sure that claims are not being adjudicated for members no longer eligible for pharmacy benefits.

For more information on the AuditRx® program, visit us on our website or contact us at (888) 797-2479 today!