People who know Pharmacy Benefit ManagementAuditing is the tool used
by managed care organizations, insurance companies, self-funded employer, drug
manufacturers and state and local governments that employ pharmacy benefit
managers to verify that they are being billed for the correct contracted network
rates, rebates and administrative fees. It is a good idea to examine the
practices of the vendors you are put so much faith in and trust to handle such a
large portion of the benefit funds.
For any health plan sponsor, the problem is multi-faceted. First, it is likely that there is a
spread between the AWP reimbursement to the pharmacy and the AWP bill submitted
to the payor. Second, PBMs are responsible for setting up and assuring
compliance to the sponsor’s benefit plan. Third, PBMs are expected to maintain
principled and professional relationships with community pharmacies and not
drive them out of business. In terms of contracting and rebates, there are times
when different departments within a PBM are at odds, there can be a conflict of
interest. Lastly, Payors need a PBM to monitor waste, abuse and fraud and make
provision to reduce or eliminate these concerns.
Audits can range from
high level to a level of detail reviewing PBM system edits. If the promised
results are not showing, the plan sponsor needs to uncover the problems and can
do so through an audit. All items identified for recovery need to be documented
back to the Payor for review and action.
A Plan Sponsor should
always validate their PBM’s contract terms, performance guarantees and savings
promises.