Modern medicines save lives and have contributed mightily to improved quality of life for many. But each year, they become more expensive and strain health plan budgets. That's why employer-funded plans are wise to schedule an Rx audit routinely. Having skilled auditors review each claim payment can find mistakes of any kind. Today, advanced systems with powerful proprietary software can instantly check for hundreds of data points. It provides a clear insight into every claim and contributes to thorough reports. When you're analyzing growth in medication costs, audit reports are insightful.

There are some "low-hanging fruit" aspects to an Rx audit, like checking to ensure generics are dispensed when available. Allowing higher-priced name-brand products to slip through when there are lower-cost alternatives of equal quality is pointless. Most pharmacy benefit managers are vigilant, but even the best can miss some. When an auditor finds and flags them, it keeps the PBM on its toes to avoid future mistakes. If performance guarantees are built into your agreement, money might come back if expenses fall outside your formulary. The only way to know is to run a claim audit.

Discounts and rebates are also a prominent part of medication costs and billing. Ensuring you're paying discounted prices and receiving the promised rebates also matters. They can add to significant sums over a year, and keeping them on track is crucial. It's one more way that a claim audit pays for itself and often contributes to the bottom line. If you have unexpected variations during a plan year and need to give management an update, the data from your auditor's report is helpful. In addition to recovering past overpayments or errors, factual data is valuable in future negotiations -- independent oversight helps.

When interviewing prospective audit firms, look for those with a proven track record of auditing pharmacy benefit plans. Each benefit offering is unique, and the things to watch for vary. Finding a firm that will carefully add your plan's provision to its system is crucial, as it will determine the claim review's accuracy. When you have better data, you're also in a stronger position for performance review meetings with your PBM. They have access to data from their systems, and you'll have an independent analysis to compare. When you find irregularities, they often suggest where system fixes are needed.