A PBM audit could uncover mistakes like incorrectly applied network discounts, mail-order discounts, specialty discounts, rebate payments, administrative fees and other program fees.
Other potential findings include incorrect application of member or drug coverage eligibility rules, cost-sharing rules, prior authorization, step therapy and override rules. These mistakes might add up to be very costly for employers.
"We've seen audits that have identified millions of dollars in recoveries," says Brian Bullock, president of The Burchfield Group, a St. Paul, Minn.-based firm that provides PBM audits and contract negotiations. Sounds pretty good; I'm sure you wouldn't turn away from potential millions, right?
However, audits can be ineffective for plan sponsors if their PBM contract includes too many auditing restrictions.
