Modern medicines play a crucial role in saving lives and enhancing the quality of life for many people. However, their costs increase each year, straining Rx plan budgets. This is why it is wise for employer-funded health plans to engage in healthcare audit services. Having experienced auditors examine each claim can uncover various errors. Today, sophisticated systems equipped with advanced proprietary software can quickly analyze hundreds of data points, offering clear insights into every claim. When looking at rising medication costs, audit reports can provide valuable information.

One of the straightforward aspects of a prescription audit is ensuring that generics are prescribed when available. Allowing higher-priced brand-name drugs to be dispensed without considering lower-cost, equally effective alternatives is unnecessary. Most pharmacy benefit managers (PBMs) are vigilant, but even the most diligent can overlook some instances. When an auditor identifies and points these out, it prompts the PBM to be more cautious and avoid mistakes. If your agreement includes performance guarantees, you might recover funds if expenses exceed your formulary guidelines.

Additionally, discounts and rebates are significant components of medication expenses and billing. These can accumulate to substantial amounts over a year, making it essential to keep track of them. A claims audit can be a valuable investment that contributes positively to your financial picture. If you encounter unexpected cost variations during a plan year and need to inform management, the data from your audit report will help. You recover overpayments or correct errors from the past, and having factual data is also beneficial for future negotiations—independent oversight adds credibility.

When considering audit firms, prioritize those with a proven history of successfully auditing pharmacy benefit plans. Each plan is distinct, and the key focus areas may vary. Finding a firm that can seamlessly integrate your plan's specifications into its system is essential. With improved data, you'll be in a stronger position during performance review meetings with your PBM. They have access to their internal data, but you will have an independent analysis for comparison. Identifying any discrepancies can often lead to recommendations for necessary system improvements.

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