RETROSPECTIVE PBM AUDIT
Our in-house team has developed propietary computer software that evaluates a series of claims from a past period to determine if a PBM has met the various terms and requirements of a contract between the PBM and the Insurer. All findings of contract deviations are then reported to the Insurer for recovery against the PBM.
MHA will readjudicate 100% of all retail and mail order claims for a targeted time period to identify recoveries in areas such as:
- Exclusions and prior authorizations
- Usual and Customary Charges
- AWP Pricing
- MAC Pricing
- Co-payments
- Member Eligibility
- Duplicate Payments
- Invalid Prescribers
- Specialty Drugs
- Formulary Overcharges
- Package Size Errors
- Mail vs. Retail Price Differences
- Professional and Administrative Fees
- Claims History vs. Payments to PBM
|
