Health plan and pharmacy benefits designs have become increasingly complex. Today there are several hundred different benefit plan designs in existence: one large national Blue Cross and Blue Shield plan alone has more than 2,000 live benefit design offerings. And each benefit design offering is typically customized for each employer client or for the market your plan operates within. That, plus the fact that member benefit designs and PBM systems often change annually, means the chances for errors are high.
These errors can wreak financial and other havoc on your individual plan members – and increase health plan regulatory compliance risks. Conducting a pharmacy benefits plan audit can help health plans determine if their PBM vendor is properly administering the pharmacy benefits to the member on the plan’s behalf – and take proactive steps to get problem areas resolved.
For commercial plans, conducting a pharmacy benefits plan audit offers several advantages:
About 40% of pharmacy benefits plan audits identify errors in how member benefits are being administered by the PBM, and these often result in significant added member costs. It is particularly important to consider conducting a pharmacy benefits plan audit under the following circumstances:
For Medicare Part C and Part D plans, doing a pharmacy benefits plan audit is also important from a CMS compliance perspective. Even though PBMs are generally aware of all existing and new CMS rules, they often don’t know how to correctly operationalize and implement these requirements from a claims processing and billing perspective. This means things often don’t work correctly in the system, resulting in members being charged incorrect amounts.
During CMS routine audits, CMS auditors typically zero in on making sure Medicare members aren’t being rejected or overcharged – and look closely at benefit-specific coding and processes. Given that CMS changes member benefit thresholds and calculation rules each year, it’s good to conduct a pharmacy benefits plan audit to make sure your PBM is complying.
Other CMS compliance areas that can be avoided by conducting a thorough pharmacy benefits plan audit of your PBM include:
Often, a health plan and a PBM may have different interpretations of a Medicare rule and how it should be implemented in the system. Another advantage of working with an outside pharmacy benefits plan auditor is that the firm, not the plan, can ask CMS directly for clarification on any discrepancy. The plan can then work with the PBM to implement the rule correctly and remain anonymous to CMS.
Auditing your PBM for accuracy in administering member benefits can also help your plan anticipate and avoid certain pitfalls that put your members – and your plan – at risk.
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