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• TFG Partners, LLC

  • 1 posts
  Posted in the topic Company Rx Plans Benefit from Claim Audits in the forum News and Announcements

  July 29, 2025 12:26 AM PDT

  Employers who self-fund their employee benefits should prioritize reviewing pharmacy claims with each health plan audit they conduct. In addition, before signing a new pharmacy benefit manager agreement, it's wise to engage a PBM RFP consulting service. While formularies direct medication usage, it's a common misconception that pharmacy claims require less scrutiny compared to medical claims. The findings from a thorough review can be pretty enlightening. For instance, you may have been promised specific rebates and discounts on certain medications—are you receiving them?

  A claim auditor can help verify the accuracy of the information provided by your pharmacy benefit manager (PBM). Additionally, it's worth noting that cases occasionally arise where name-brand drugs are dispensed in place of their generic counterparts, leading to unnecessary costs. Today's leading auditors review claims with a keen sense of where discrepancies may arise. The alignment between their auditing setup and your benefit plan's provisions is crucial; the more synchronized, the better they are, the more reliable the audit results will be. It yields improvements in both the short and long term.

  Unlike in the past, when audits relied on random sampling, modern approaches ensure that every claim is reviewed. This shift represents an improvement, mainly because the parameters for prescribed medications are more straightforward: either eligible members received the correct medications, or they did not. The top auditors possess specialized methods for pharmacy claims, which differ from those used for medical claims. This expertise enhances accuracy, making it easier to identify expensive issues. With the escalating prices, the importance of accurate claim processing is obvious.

  Even if continuous monitoring of pharmacy claim payments isn't currently in place, it's advisable to conduct regular reviews. Many employers have discovered that rectifying errors after a considerable delay is more challenging than addressing them promptly. Mistakes tend to recur, so early detection and correction simplify the process. As you prepare your budget for the upcoming year, conducting an audit to validate trend data and uncover cost-saving opportunities is a wise decision. The expense associated with this auditing service is outweighed by the potential savings identified through the audit findings.