Auditing

           Prescription Claim Audit
           Performance Standards
           FWA Auditing
           PBM Invoice Reconciliation

             Vender Management
             Reporting
             Clinical Services
             Medicare Specific Services

Auditing 

Prescription Claim Audit

Independent Pharmaceutical Consultants/EvergreenRx (IPC/EvergreenRx) policy is to audit 100% of the claims filled within the defined audit period and provide our clients a performance review of the contracted discounts, benefit design, and clinical program accuracy. IPC/EvergreenRx shares the draft report with the PBM for their comments. The final Audit Summary Report then includes the Pharmacy Benefit Manager’s (PBM) response to the audit findings, summary of the financial impact for the audit findings and recommendations from us to improve plan performance and/or effectively correct any audit identified deficiencies. IPC/EvergreenRx’s detailed Prescription Drug Claim Audit includes:

• Re-pricing of claims using the contract discount guarantees
• Application of benefit design and clinical edits to claims
• 100% audit of claims filled within defined audit period
• Performance review of contracted discounts, benefit design, and clinical program accuracy
• Recommendations to improve plan performance

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Performance Standards

Review each client’s administrative services agreement with their Prescription Benefit Administrator (PBA) to ensure they provide consistent and timely measurement of performance guarantees as well as focus on member health and safety.

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FWA Auditing

Fraud, Waste and Abuse (FWA) detection and management is a process of growing importance to both Federal and State government vendors and to plan integrity for commercial sponsors. IPC/EvergreenRx has developed a series of edits through which the claims are subjected, providing a report including potential areas of FWA for action by the Client or Client’s PBM.

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PBM Invoice Reconciliation

IPC/EvergreenRx compares the client’s claims to the invoices to assure the client is being invoiced correctly by the PBM. This process includes:

• Review and compare each invoice to the corresponding claims for that payment period.
• Review plan cost and administrative fees.
• Review any additional elements that may be included on the PBM invoice.
• Assess practicality of the billing.

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