Pharmacy Plan Audit

Self-insured employers require assurance that Pharmacy Benefit Managers pay prescription drug claims accurately and appropriately according to formulary and terms of the administrative agreement. To achieve this goal, HDM conducts a comprehensive review of PBMs including a claims audit and rebate audit. 

The following services can be included in a pharmacy plan audit:

HDM analysis on 100% of prescription drug claims including retail and mail order programs.

Onsite Audits at PBMs

HDM auditors will visit the PBM to review the control environment, review claims analysis and perform a rebate audit. Auditors will evaluate the effectiveness of PBM policies and procedures to administrator our customer's prescription drug program.

Rebate Audit  

A rebate audit is conducted to determine the accuracy of rebate payments from the PBM to our customers. Reconcile payments with claims data to ensure correct dollars were paid to our customer by matching dollars paid to PBM within manufacturer contracts and formulary requirements.

Financial Reconciliation

Perform a financial and funding reconciliation, utilizing PBM reports and customer banking records. Review adequacy of the funding requests and reconcile all funding and payment banking records. Thus assuring there are adequate controls over financial transactions.  

Overpayments & Corrective Actions  

Present validated claim errors and overpayments to the PBM for recovery. Negotiate and monitor recovery collection activity to ensure recovered dollars go to our customer.

If you have questions about this web site or need assistance e-mail info@hdminc.com or call 1-800-859-5119.

 

Types of Audits

Medical Plan Audit Pharmacy Plan Audit Dental Plan Audit Hospital Bill Audit Eligibility Audits

Value by Department

Corporate Finance HR/Benefits Internal Audit IT Department Healthcare Vendors Consultants

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