Pro Pharma performs Retrospective Pharmacy Claims Audits to ensure compliance with PBM contracts. These audits fall under the accounting rules for Attestations. Pro Pharma is sensitive to conflicts over audits and makes every effort to identify areas requiring validation and to work with all parties to ensure contract co0mpliance.
Fundamental areas for audit are, but not limited to:
- Formulary Compliance
- Pricing/MAC Compliance
- Invalid Claims
- Excluded Benefits
These audits review invoices with the pharmacy claims over the audit period. These screens also target the Providers, Physicians and Pharmacies responsible for rejected claims that did not meet contract requirements, or for which continued monitoring is recommended.
Benefits of Retrospective Auditing of Pharmacy Claims are a Management Tool that maintains contract compliance as well as identifying management targets:
- Pro Pharma performs 100% Pharmacy Clams Audits and places them on the cloud for immediate review and validation
- Pro Pharma’s digital approach to pharmacy claims audits provides fast, efficient, and affordable auditing
- Pro Pharma’s approach is always the lowest cost option for auditing to ensure contract compliance
- Pro Pharma’s audits require digital supporting information to expedite the process and make it exhaustive, but affordable
- Peripheral Identification of Physician and Pharmacies responsible for outlier and/or for potential “abuse”