5 steps to correct PBM plan set-up errors

By Chris Hanson-Ehlinger
Fri, Feb, 27, 2015 @ 14:02 PM

LynnStaufferNothing is more disconcerting (and potentially costly) than to learn your PBM is not paying your claims correctly. If you get the bad news, take immediate action. Follow these five steps with your PBM to assess and resolve the error.

1. Identify the root cause

Get to the bottom of the problem. Your PBM needs to find out exactly where the chain broke in the implementation process. Often it’s something as simple as miscommunication or human error.

2. Determine the scope

How many members were impacted and how many claims? Did the error affect all of your plans or just a subset? Ask your PBM to isolate the error and confirm the extent of the damage.

3. Implement a stop-gap process to prevent further errors

Ask the PBM communicate the setup error to its customer service team to minimize member disruption. The PBM should monitor all claims paid under the impacted benefit to seal any cracks.

4. Take corrective action to resolve the issue

Have the PBM draft a comprehensive corrective action plan (CAP) that details actions put in place to address the issue. Make sure to review the CAP make adjustments as necessary. 

5. Continue targeted monitoring

To assure the issue is completely resolved, have the PBM monitor specific claims for three months after the CAP is in place. Ask for reports demonstrating that the issue had been corrected.

Wrongly paid claims erode confidence in your PBM. Are there other issues? Is the PBM’s reporting accurate? Save yourself months of headache by addressing the situation right away and following it through to resolution.

Lynn Stauffer is an audit lead at The Burchfield Group specializing in Medicare compliance. For more information, please call 800-778-1359 or send us a note (http://www.burchfieldgroup.com/contact/).

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