1 Back to BLOG

Plan Design Audit - A Powerful Tool

Most people have heard the joke about the only things that are certain are death and taxes.  Another item that could be added to the list is the rising cost of pharmacy benefit costs. Not only has this become a serious problem, but the tide is not turning yet and costs continue to escalate.

To attack these health care benefit costs, one arrow in your quiver is the pharmacy plan design audit.  Although it’s not the most utilized type of audit, it can be powerful.  Consider the complexity involved in adjudicating today’s complex plans which involve, copays, quantity limits, exclusions, network restrictions, exceptions, prior authorizations, etc.  There are a lot of opportunities for a claim to get processed incorrectly. When this happens, the cumulative effect can often be costly to the plan.

Errors can be made in applying a copay incorrectly for a specialty drug, or a claim paid for an excluded drug. Claims could also be paid for prescriptions paid at a pharmacy excluded from the network or a manually processed claim that didn’t meet a plan’s specifications.  Another plan design feature that can prove costly if not adjudicated accurately is reference based pricing.  

The plan design audit process compares how claims were adjudicated over the time frame of the audit to how they should have been adjudicated and provides the plan sponsor with valuable insight into how the plan is performing.  This step can save the plan money and put the plan on a better trajectory going forward.

Getting the process started requires a pharmacy claim file, plan setup documents, all plan change documentation, an excluded drug list, and specialty drug and preferred drug formulary lists specific to the plan.