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Armstrong Libraries Group

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Let Claim Audits Help As Drug Prices Rise


Coping with rising costs strains every pharmacy and medical plan. As new medicines come to market each year, prices rise further. Running an Rx audit can help because it flags missed discounts and rebates, confirms your formulary is followed, and finds other mistakes – you'd be surprised how often name-brand medications are dispensed instead of generics. When auditors flag these and other irregularities, your pharmacy benefit manager tightens up controls. There is no substitute for independent oversight and accurate verification with your plan's provisions in sight.


It's helpful to have auditors specializing in prescription plan audits and understand the likeliest places for claim administration errors. Such insight establishes the baseline for an audit, and the rest goes according to your plan's unique provisions. Knowledge of pharmacy operations also helps, and auditors who bring that expertise add more value. Their work covers the standard audit bases but layers on an extra understanding of the claims payment process. Some firms have ex-PBM managers on staff, and they can review claims with greater precision. Each audit firm maintains its software and systems uniquely.


Extraordinary events like the COVID-19 pandemic are thankfully rare, but having a solid oversight structure in place is beneficial when they happen. During the pandemic, pharmacy and medical plans were hit with extraordinary costs, and auditors helped review the expenses. In cases where mistakes were made, or agreements were overlooked, plans could request repayment based on audit findings. Claims are the same as blank checks, and when errors are made, refunds are appropriate. PBMs were affected by how medical claims administrators were during the pandemic, and no one was doing their best work.


You satisfy regulatory and compliance needs with pharmacy claims audits, but they have greater value thanks to today's accurate systems. You can tap their potential for cost containment programs and member service upgrades when considering claim reviews as strategic management tools. Everyone benefits when claims are paid accurately. Consistent outstanding performance depends on multiple management factors, and keeping your pharmacy claims on track matters. C-suite management reporting to boards and shareholders also appreciates and benefits from pharmacy claim oversight.

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