In an era of inflation and relentlessly rising prices, running an Rx audit to double-check claim payments makes excellent sense. It's a tool often used by employer-funded prescription plans relying on pharmacy benefit managers to handle their claims. Billing for medicines has its own system and includes discounts and rebates. Things can fall through the cracks when thousands of claims are processed weekly. Does your PBM advocate for your plan adequately? Claim audits can answer these questions and shed light on details you might not see otherwise, thus their significant value.
There is also some low-hanging fruit that a claim audit can pick up and bring savings. For example, when higher-priced name-brand medications are dispensed instead of lower-cost generics. Most PBMs have electronic systems to prevent such errors, but they can and do occur. It's another case where comparing an auditor's report against error self-reporting from your PBM (if your agreement contains error-reporting provisions) can be enlightening. When routine oversight is in place, you'll likely see performance improve; if it does not, you'll have factual data to drive needed changes.
It's wise to run a medical claims audit at the same time you review your self-funded plan's pharmacy payments. It's a different audit procedure for medical claims because they vary widely from those for prescriptions. However, most specialist audit firms have dual capabilities and understand the differences. Because of coding and other complexities, examining every medical claim paid can yield significant savings when irregularities and overpayments are flagged. It's common and laudable for outsourced claim processors to have ultra-low error rates. However, claims are expensive, and reviewing payments helps.
As audits have become more powerful, drilling down into complicated claims data is more manageable. You can expect more thorough and detailed reports customized for your plan. The best claim auditors carefully add your plan's provisions to their systems in detail before running the claim review. It assures you of more accurate error detection because the system will understand more about your plan's unique attributes. It's always wise to run an audit with general concepts in mind, but things can be overlooked unless it is customized for your plan. The purpose is to catch virtually all irregularities.
Company Name- TFG Partners, LLC
Address- 437 Grant St #1020, Pittsburgh, PA 15219
Contact Number:(412)-281-2228
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