Part D Audit & Compliance Tool (PACT) -Gorman Health Group

Health plans and Prescription Drug Plans (PDPs) that utilize PBMs to offer Part D are required by CMS to implement compliance programs to ensure that the PBMs accurately administer and process prescription claims. This is no small task, given that on the commercial prescription benefit side, an estimated 3%-10% of all PBM-processed prescription claims have errors.

Participating Medicare Part D plans that do not develop and implement a fully functional PBM compliance program run the risk of running afoul of CMS auditors charged with monitoring the program for potential fraud, waste and abuse. Failure to identify and fix PBM-processed claims discrepancies can result in sanctions, stiff financial penalties, and disrupted operations.

That’s why Gorman Health Group has teamed up with Axia Strategies and Pharmacy Outcomes Specialists – two of the nation’s most experienced pharmacy claims and drug rebate auditing firms – to offer PACT, our Part D Pharmacy Audit and Compliance Tool, a two-part solution:

Part One Detail

Part Two Detail

Part One:

is a customizable, compliance template for plan sponsors to assess any gaps or discrepancies in how their PBMs are maintaining drug claims; proactively identify potential instances of fraud, abuse or waste; and determine whether the PBM is meeting all contractual requirements. Health plans can use this template to implement a self-directed PBM claims compliance program that fits their size and volume of activity. Conversely, health plan sponsors can choose to outsource this claims compliance function entirely to GHG and its partners, so plans can receive objective and actionable feedback from outside experts, while staying focused on their core operations.

Part Two:

is a full Medicare Part D claims audit service that includes a thorough, post-implementation (30-45 days) review of all prescription claims to identify potential discrepancies and evaluate these for accuracy and contract adherence by the plan sponsor’s PBM. It also includes a subsequent “mid year” review in which all claims during a three-month period will be audited, then compared with drug rebate audit data. This allows plans sponsors to make any re-pricing adjustments that might be necessary to ensure that all discounts and rebates have been properly accounted for and reported to CMS – as required by federal regulations.