Pro Pharma has consulted to Health Plans, Municipalities, and Self-Insured Companies since 1985 to provide PBM Oversight and Management. It is just as important to keep an eye on PBM activities and outcomes, as in managing your budget. In fact, our Clients have found that PBM Oversight in some shape or form on a continuing and ongoing basis, is favorable to budget.
Pro Pharma has consulted to Health Plans, Municipalities, and Self-Insured Companies since 1985 to provide PBM Oversight and Management. It is just as important to keep an eye on PBM activities and outcomes, as in managing your budget. In fact, our Clients have found that PBM Oversight in some shape or form on a continuing and ongoing basis, is favorable to budget.
Fraud, Waste & Abuse at Work
Problem: One of our large Health Plan Clients was concerned that their Pharmacy Benefit Manager (PBM) was not adjudicating their Pharmacy Claims according to agreed upon Contract terms. Their costs were skyrocketing, and most especially with Specialty Drugs.
Methodology: Pro Pharma analyzed and reviewed 100% of the Health Plan’s Pharmacy Claims for the most immediate 12-month period. In that way, Pro Pharma can pinpoint the areas of greatest concern and illustrate key issues for the Health Plan. The areas that pose the greatest concern are in:
- Formulary Compliance
- Eligibility
- Pricing & MAC List Compliance
- Invalid Claims
- Excluded Benefits
The analyses and in-depth monthly virtual meetings with the Health Plan provided insights and specific examples of Outliers to communicate and illustrate concerns to their PBM.
Outcome: Initially the Health Plan advised the PBM that they were going to continue oversight and monitoring each month. Pro Pharma communicated with the PBM on behalf of the Health Plan to discuss the potential areas of savings opportunities and gave direction to the PBM to respond within one month with corrective action plans. This created a platform for discussion and follow-through on an ongoing basis. Estimated savings based upon size of Client is 42% with an ROI of 6 to 1. Actual savings depends on the Client’s appetite for pursuing identified issues with the PBM.
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