Post-implementation audits are a good business practice when changing PBM vendors

By Chris Hanson-Ehlinger
Thu, Jan, 02, 2014 @ 13:01 PM
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Let’s say you’ve changed your prescription drug plan or maybe even selected a new PBM vendor. Your team is working closely with the PBM to follow the implementation plan and make certain the transition is as seamless as possible. What could possibly go wrong? Unfortunately, the answer to this question is…plenty!

That’s why every plan sponsor should consider a post-implementation audit any time a significant plan or vendor change is made. Today’s prescription drug benefit bears little resemblance to the benefits of even a few years ago. The level of complexity is remarkable. Consider the features frequently found in current plan designs:

  • Within one sponsor’s benefit offerings it is not unusual to find multiple copayments, coinsurance, minimums, maximums, deductibles, out-of-pocket limits and other accumulators.

  • A combination of Health Reimbursement Accounts (HRA), Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) is the norm rather than the exception.

  • Many plans have implemented limited or preferred pharmacy networks and formulary restrictions to encourage member cost saving behaviors.

  • Plans employ clinical initiatives such as step therapy, prior authorization and quantity limits to manage appropriate, cost effective utilization.

  • Health care reform requirements, coordination of benefits and eligibility file transfers all require close attention.

  • Timely and accurate communication of pharmacy claims to other vendors is critically important for wellness programs, case management, data management and auditing to function efficiently.

Many more items could be added to this list to further confirm the complexity present in many prescription drug plans. The number of moving parts makes the task of transitioning between vendors difficult. PBMs invest considerable resources into their implementation process but even the best plan presents opportunities for set-up errors.

The best and fastest way to identify and correct implementation errors is to conduct a post-implementation audit. The audit, conducted by an independent expert, typically takes place 90- to 120-days after the start date. A retrospective claims review looks for discrepancies or deviations from the desired plan set-up. If errors are found, the PBM is notified and all necessary corrections are made early in the plan year—before they compound into a much larger problem.

Audits are sometimes viewed as a difficult or uncomfortable exercise. Plan sponsors may be reluctant to audit their PBM due to concern that it may stress the client-vendor partnership. In reality, audits are a good business practice. They help plans manage drug benefits as accurately and efficiently as possible. A pharmacy benefit consultant is a good resource to conduct the audit and resolve discrepancies with your PBM.

Craig Oberg, RPh, is a managing consultant at The Burchfield Group. He works with national employers to develop strategic PBM management plans. For more information on this topic or related matters, please call the The Burchfield Group at 800-778-1359 or send us a note (


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