CGI Federal Inc. undertook a complete pharmacy claims audit of a major central U.S. State’s Public Employee Plan’s commercial business
CGI Federal Inc. undertook a complete pharmacy claims audit of a major central U.S. State’s Public Employee Plan’s commercial business. The pharmacy claims history spanned twenty-four months of electronic prescription transactions. 766,366 claims were paid totaling $33,539,417 within this period. The plans fell into several plan categories with multiple variations in benefit design within each category. The categories included a HMO, PPO and a major medical plan prescription benefit. Five unique pharmacy networks and two unique mail-order pharmacy vendors were used to provide prescription services to subscribers. The Plan also utilized a generic Maximum Allowable Cost (MAC) schedule from a contracted PBM to price generic drugs.
How CGI Helped
Specific audits pinpointed prescription claims with unrealistically high quantities dispensed, claim dollar levels and utilization rates that were researched and shown to be misfilled or improperly filled at the pharmacy level. The audit system, including various analyses of subscribers, pharmacies and physicians, also highlighted instances where case management and utilization review would be likely to save prescription benefit dollars in the future with intervention strategies. The subscriber data highlighted members with the highest utilization rates, utilizing the highest cost medications, and with the greatest dollars in prescription spending. The pharmacy and physician data was sorted to view providers who would provide the greatest return from intervention strategies in the areas of Dispensed as Written (DAW) prescription conversions and generic compliance.
Of particular interest in this case was the fact that NMIS compliance auditing was being performed throughout the two-year period to ensure the integrity of the plan, yet these instances occurred undetected.
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