| |
BUSINESS PRACTICES AUDIT
The business practices audit measures the potential of a PBM to effectively manage its claims handling actions. The audit determines if all terms in the contract are completely auditable, evaluates the transparency of the adjudication methods, and examines price spreads used by the PBM that could artificially increase the Rx spend.
Examples of Retrospective Business Practice Audits include:
- Verify Pricing Source used has lowest AWP
- Repackaging is not being used to inflate prices
- Higher priced drugs are not being placed on formularies “Formulary Steering”
- Brand/Generic Status not being manipulated
- Members copay are not more than the cost of the drug “Zero Balance Prescriptions”
- Mail Order is actually saving you money
- Does PBM allow fraudulent Rx’s to be reimbursed.
- Is MAC pricing being manipulated to increase your Rx Spend?
|
|
