PBM Pricing Audit
Ensure correct pricing for Part D claims. CMS requires MA-PD and PDP plans to maintain ongoing monitoring of their Medicare Part D programs. This includes a thorough understanding of the performance of the subcontracted PBM and utilization activity.
Through our partnership with TRICAST Inc., we offer you a sophisticated Medicare Part D audit and oversight service to enable your plan to achieve optimal financial oversight while staying compliant. The services include:
Network Pricing and Plan Audit
- AWP Discounts, Definitions and Guarantees
- Review “lower of” claim pricing adjudication logic
- Application of MAC pricing and discount analysis
- Lock-In or Pass-Through networks analyzed
- Administration of formulary, duplicate payments, refill limits
- Review of proper application of co-payments and co-insurance
- Review of non-covered drugs
- Review of drugs requiring prior authorization
- Rebate assessment
PDE Financial Audits that compliment our PDE reconciliation program
- Claims file match with total drug costs and member paid
- Troop calculations verified
- Assessment of B vs. D drugs submitted
Fraud Waste and Abuse – A view from Multiple Data Sources
There are multiple challenges in tracking Fraud Waste and Abuse that may not be fully captured in PDE data analysis and require source claim and medical data inclusion. Verification of the following requires dynamic tools that integrate various data sources to confirm suspected cases of FWA.
Examples of FWA monitored include:
- Outlier utilization
- High cost claim monitoring
- Inappropriate pharmacy network pricing
- Multiple members utilizing one card
- Narcotics monitoring
- Paper claim submission integrity
Further, medical data inclusion enables a broader FWA oversight effort:
- Diagnosis and verify drug use to ensure the right drug went to the right person
- Specialty drug dispensing to verify corresponding disease diagnosis
Immediate Response Opportunity for Your Plan
Our reporting criteria are dynamic and adjust based on your data patterns. Reporting is calibrated for immediate web access or daily push reporting, enabling unsurpassed independent monitoring of claims activity. Report cards are generated on frequency designated by you.
For more information on our Part D claims audit services, please contact 202-364-8283.
