Employer Audit Procedure
The primary steps of the audit process are 1) Distribution of legal documents 2) Collection of information and data 3) System input and quality control 4) PBM reconciliation of discrepancies and 5) Audit reporting.
Legal documentation-
1) Signed contract between the Client and SPS for audit services
2) NDA and possibly a BAA between the PBM and SPS and Client to ensure the privacy of data transfer and proprietary protections in conducting the audit
Collection of information and data-
From client-
1) SPS will supply a letter format “Letter of Authority” that would need to completed and send to the PBM. This serves notice of the audit and names SPS as the contracted audit vendor
2) A copy of the PBM Services Agreement and any amendments with the PBM
3) Any Summary Plan Documents or Explanation of Benefit information of the intended plan design
4) If available, any Plan Design setup form used by the PBM that approves the intended plan protocols and drug coverage for the plan
From the PBM-
1) Completion of our Audit Questionnaire
2) Supplied documents and files (approximately 20) listed on the Questionnaire pertaining to procedures, pharmacy IDs, exceptions, MAC pricing, etc that will be needed to duplicate the claim processing
3) Complete data file of processed claims for the audit period
System Input and Quality Control-
With all the information collected, our pharmacists and technicians will load the ProbeRx® software input screens for the audit. The initial run will be inspected for logic and accuracy as a check of both input and an analysis of the information given. Often this step reveals missing information or plan design changes not given by the PBM audit department.
PBM Reconciliation-
After preliminary audit runs are corrected and our staff is confident the discrepancies are accurate, sample discrepant claims are sent to the PBM for review. Conference calls and web meetings for viewing the questionable claims help SPS and the PBM staff finalize the true audit results.
Audit Reporting-
The ProbeRx® software automatically produces an Audit Summary, along with a detail back-up file of all the discrepant claims. Several additional reports are generated to give the detail of claims found to non-compliant due to processing errors involving Step Therapy, Refill Too Soon and Quantity Limits. An additional report, the Executive Summary Report, will identify the individual categories and totaled amounts where claims were discrepant. This also has a detailed back-up file of individual discrepant claims.
Project Timeline
Following our approach procedures above, we will set timelines for the various stages and track progress as we go along. The audit process may take a minimum of 3 months to complete but the actual time involved is mostly dependent on the follow through of the PBM delivery of information.
Note: Your PBM has the data and all needed information for the audit so client involvement is minimal. If needed, we will occasionally enlist the Plan management to help speed the delivery of information from the PBM. We will give you regular updates of the audit progress as needed and make a formal presentation of results at the end of the audit.
The primary steps of the audit process are 1) Distribution of legal documents 2) Collection of information and data 3) System input and quality control 4) PBM reconciliation of discrepancies and 5) Audit reporting.
Legal documentation-
1) Signed contract between the Client and SPS for audit services
2) NDA and possibly a BAA between the PBM and SPS and Client to ensure the privacy of data transfer and proprietary protections in conducting the audit
Collection of information and data-
From client-
1) SPS will supply a letter format “Letter of Authority” that would need to completed and send to the PBM. This serves notice of the audit and names SPS as the contracted audit vendor
2) A copy of the PBM Services Agreement and any amendments with the PBM
3) Any Summary Plan Documents or Explanation of Benefit information of the intended plan design
4) If available, any Plan Design setup form used by the PBM that approves the intended plan protocols and drug coverage for the plan
From the PBM-
1) Completion of our Audit Questionnaire
2) Supplied documents and files (approximately 20) listed on the Questionnaire pertaining to procedures, pharmacy IDs, exceptions, MAC pricing, etc that will be needed to duplicate the claim processing
3) Complete data file of processed claims for the audit period
System Input and Quality Control-
With all the information collected, our pharmacists and technicians will load the ProbeRx® software input screens for the audit. The initial run will be inspected for logic and accuracy as a check of both input and an analysis of the information given. Often this step reveals missing information or plan design changes not given by the PBM audit department.
PBM Reconciliation-
After preliminary audit runs are corrected and our staff is confident the discrepancies are accurate, sample discrepant claims are sent to the PBM for review. Conference calls and web meetings for viewing the questionable claims help SPS and the PBM staff finalize the true audit results.
Audit Reporting-
The ProbeRx® software automatically produces an Audit Summary, along with a detail back-up file of all the discrepant claims. Several additional reports are generated to give the detail of claims found to non-compliant due to processing errors involving Step Therapy, Refill Too Soon and Quantity Limits. An additional report, the Executive Summary Report, will identify the individual categories and totaled amounts where claims were discrepant. This also has a detailed back-up file of individual discrepant claims.
Project Timeline
Following our approach procedures above, we will set timelines for the various stages and track progress as we go along. The audit process may take a minimum of 3 months to complete but the actual time involved is mostly dependent on the follow through of the PBM delivery of information.
Note: Your PBM has the data and all needed information for the audit so client involvement is minimal. If needed, we will occasionally enlist the Plan management to help speed the delivery of information from the PBM. We will give you regular updates of the audit progress as needed and make a formal presentation of results at the end of the audit.