Pharmacy Benefit Management Audit - Moody Associates, P. A.

Pharmacy Benefit Management (PBM) Auditing

Self-Insured Companies and Health Plans:
With healthcare costs skyrocketing, shouldn’t you have the confidence that your PBM is paying your claims accurately and acting in your best interest per the terms of the agreement you have negotiated? PBM audits typically yield between a 3% to 8% savings on pharmacy costs.

Moody Associates (M&A) professionals will provide you with a risk free analysis of your PBM to provide you with the assurance that your healthcare claims are being paid accurately and that plan members are not being pushed into delivery methods that are not cost effective for the member or your organization.

Pharmaceutical Manufacturers:
Pharmaceutical companies audit PBM’s due to industry and government regulations, as well as, wanting assurance that rebates and administrative fees being paid to PBM’s are accurate.

M&A will provide you with professionals that will accomplish your goals. We can provide you with a customized audit solution to provide you with a comprehensive contract compliance review including, but not limited to: government pricing restatement, formulary profiling, intervention and marketing analysis, adjudication testing, and rebate recalculations.

Deliverables

M&A’s PBM audit services give our Clients the assurance that their PBM’s are adhering to the terms and conditions that both parties negotiated. M&A’s Accountants will assess compliance and promptly present you with fully documented reports of overpayments made to your PBM. We will provide you with reporting that includes an executive summary, our approach, audit findings and practical recommendations for future cost savings.

M&A PBM Audit Approach

M&A’s methodical and well-planned PBM audit approach is as follows:

Stage 1: Obtain and Analyze Data

Obtain and understand all contracts and addendums to be audited
Obtain and understand the related claims data

Stage 2: Planning

Conduct calls with appropriate contacts at both the Client and the PBM to understand the relationships, billing and payment methodologies, perceived or known concerns, discuss timing and logistics, and to set expectations and communication timelines for the audit(s)
Perform desk audit procedures to assist in assessing risk areas to focus on

Stage 3: Fieldwork

Interview the PBM about their policies and procedures as they relate to the contract
Conduct field audit, including all compliance testing – pricing, adjudication, eligibility, delivery method, rebates, duplicate payments, funding reconciliations, etc.
Discuss audit findings and any follow-up questions that arose from the field audit with Client
Follow-up with the PBM regarding any unanswered questions

Stage 4: Reports and Recommendations

Assemble and present a draft audit report including executive summary, audit methodology, findings and recommendations to Client for review and comment
Submit our final audit report

Associated information:
Audit Recovery
Contract Compliance Audits
Unclaimed Property Consulting
Consulting Services
Health Care Claims Audit Services