Employer Audit
Why Audit My PBM?
If you are wondering if your PBM is processing your employee claims according to your contract and benefit instructions, or wondering how the many news releases of PBM lawsuits could affect your situation, you are not alone. The answer is to allow us to perform a claim by claim retrospective audit of your PBM. An audit is standard in the industry and provided for in your PBM Services Agreement.
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We have audited Fortune 500 companies and a state government employee benefit. Our proprietary software, labeled ProbeRx® was developed by the partners of SPS and covers all aspects of the processed pharmacy claim. Some vendors state they audit 100% of the claims but may only check the AWP % discount and the Dispensing Fee of the claims.
The SPS employee benefit audit inspects edits directly related to contract compliance and compares your cost per claim to your PBM Services Agreement. |
Financial Discrepancies
The SPS employee benefit audit continues with a comparison of the data results to your intended plan design, isolating issues of the PBM implementation of protocols and the basic programming logic.
Plan Design Discrepancies
Our audit input is designed to mimic the actual PBM processing procedures intended for your benefit plan. The SPS audit follows procedures involving multiple member claims, specific time periods and dispensed quantities. Examples would be Refill Too soon, Step Therapy Protocols and Quantity Limited Drugs. The actual processing of these procedures is inherent to the individual PBM programming. The audit results will highlight the impact of programming decisions made for you by the PBM.
Processing Discrepancies
Greatest expense savings: As the audit highlights problems in PBM processing, SPS will describe all processing issues with client management and then ensure unapproved PBM procedures are changed. Any lacking or unintended plan design issues are explained and discussed with the client as we ensure the best processing procedures are in place and any deviations to the desired plan design are corrected.
The audit software produces external reports that analyze the results to the contractual guarantees promised to your plan.
Contract Guarantee Discrepancies
Benefit audits frequently identify set-up errors that can be contrary to intended plan features. Benefit audits examine all aspects of the PBM processing to determine if the PBM has accurately administered your benefit.
A major result of a pharmacy audit is the increased knowledge you and your team will gain from the process. With direct reporting of audit discrepancies and PBM processing procedures, our clients relate that they have a much better understanding of the PBM industry after the audit. With better knowledge you can build a better pharmacy benefit and better understand the pharmacy contract.
View Employer Audit Video
View Management Reporting
View Employer Audit Procedure
- Wrong AWP of claim used, compared to Medispan - $
- Wrong AWP discount on Retail 30, Retail 90, Mail and Specialty - $$
- Wrong Dispensing Fee applied per Retail, 90 Day Retail, Mail and Specialty-$
- Failure to compare U&C to claim charge- $
- Claim not matched to MAC pricing list- $$$
- Missed application of contracted “alternate” Specialty pricing list of drugs- $
The SPS employee benefit audit continues with a comparison of the data results to your intended plan design, isolating issues of the PBM implementation of protocols and the basic programming logic.
Plan Design Discrepancies
- Member ineligible on date of service of claim-$
- Days Supply Limits exceeded as per Plan Design- $
- Wrong assignment of member copay or deductible- $$
- Prior Authorization procedure missing for assigned drugs- $$$$
- Missed Plan Design drug exclusions- $$$$
- Pricing errors of DAW 1 and DAW 2 resulting in loss of copay penalties- $$$
Our audit input is designed to mimic the actual PBM processing procedures intended for your benefit plan. The SPS audit follows procedures involving multiple member claims, specific time periods and dispensed quantities. Examples would be Refill Too soon, Step Therapy Protocols and Quantity Limited Drugs. The actual processing of these procedures is inherent to the individual PBM programming. The audit results will highlight the impact of programming decisions made for you by the PBM.
Processing Discrepancies
- Refill before percent of allowed Days Supply is used (Refill Too Soon)- $
- Duplicate therapy allowed for same member- $
- Lack of control of pricing on compounded medications- $
- Inaccurate assignment of Generic over Brand – wrong discount applied- $$
- Allowed use of “repack” drug sources with inflated AWPs- $
- Plan Design edits for Step Therapy protocols not followed- $$
- Plan Design edits for Quantity Limits not followed- $$$
Greatest expense savings: As the audit highlights problems in PBM processing, SPS will describe all processing issues with client management and then ensure unapproved PBM procedures are changed. Any lacking or unintended plan design issues are explained and discussed with the client as we ensure the best processing procedures are in place and any deviations to the desired plan design are corrected.
The audit software produces external reports that analyze the results to the contractual guarantees promised to your plan.
Contract Guarantee Discrepancies
- Extreme AWP $ amounts used creating false Discount % to meet guarantees
- Failure to meet contracted guarantees- $$
- Missed rebate distribution- $ to $$$$
Benefit audits frequently identify set-up errors that can be contrary to intended plan features. Benefit audits examine all aspects of the PBM processing to determine if the PBM has accurately administered your benefit.
A major result of a pharmacy audit is the increased knowledge you and your team will gain from the process. With direct reporting of audit discrepancies and PBM processing procedures, our clients relate that they have a much better understanding of the PBM industry after the audit. With better knowledge you can build a better pharmacy benefit and better understand the pharmacy contract.
View Employer Audit Video
View Management Reporting
View Employer Audit Procedure