PHARMACY AUDITS
Pharmacy audits are performed as desk audits or on site. The desk audit targets individual prescriptions that are questionable and compares hard copies to electronic data. The claims that are not meeting contract terms are reported as recoveries due to the Insurer from the PBM.
When MHA performs the analysis and targeting from raw claims data, 100% of our audits have resulted in substantial recoveries in categories such as:
- Brand billed vs Generic dispensed
- Incorrect days supply dispensed
- Unauthorized Refills dispensed
- Invalid or fictitious physicians
- Improper quantities billed
- Missing Prescriptions
- Drug Diversion
- Lack of DAW compliance
- Signature Log check
- Services not rendered
- Exceeding prescribed refills
- Returned to Stock Rx's not reversed
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