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Selection and Scoring for Onsite and Desk Audits |
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The AudiTrack© application focuses on the discovery of recoverable
pharmacy claims cost based on detailed pharmacy claims examination.
Pharm/DUR, Inc. uses a true audit based methodology, and does not use
sample data to extrapolate potential claim discrepancies when performing
an audit. We rely on the information provided by the client to ensure all
claims are validated for covered benefits at the time of service. All
elements of plan design and eligibility are audited for compliance and adherence.
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Through a number of proprietary and customized rule sets, the AudiTrack© application
will identify and report claims discrepancies. Any discrepancy, fraudulent or abusive
billing patterns will be flagged and reported to client for further determination before
proceeding with recovery. Our solutions are specific to your requirements and evolve with your changing needs.
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Pharm/DUR would expect to receive a full file of claim data in NCPDP format directly
from the claims processing system used by the client. A minimum data set file layout is
attached in the exhibits.
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In addition, to set up the proper dataset file, Pharm/DUR, Inc. would require a sample of
recent data with all paid claims, and claims file layout. Upon completion of the data file
test, complete claims data to begin the review. In order to conduct audits appropriately,
Pharm/DUR, Inc. would require plan benefit documentation, contract agreements with the PBM,
implementation worksheets, and any other documentation necessary to define plan parameters.
In the case of multiple benefit designs, we would require a benefit grid, preferably in electronic
format in order. A primary contact with a client liaison, to answer questions related to the plan
administration and benefit design as they come up in the course of the review process.
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Through a number of proprietary and customized rule sets, the AudiTrack©
application will identify and report claims discrepancies. Criteria can include but not be limited to:
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- Gross Claims Volume
- Brand/Generic Utilization
- Controlled Substance Utilization
- DAW Submissions
- One time Submissions (maintenance drugs, creams, antibiotics, Etc.)
- U&C Submissions
- Incorrect Prescriber Submissions
- Incorrect Days Supply Submissions
- Multiple Package Supply Submissions
- Percentage of prescriptions filled for a specific physician
- Maximum Dose Limits
- Submission of Stale or Outdated NDC numbers
- Compounds submitted with an indicator
- Compounds identified and Not Submitted with an indicator
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Any discrepancy, fraudulent or abusive billing patterns will be flagged and reported to
client for further determination before proceeding with recovery. Our solutions are specific
to your requirements and evolve with your changing needs.
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The AudiTrack© program processes pharmacy data for stores
that have not reached a specific claims volume. Proprietary and
pre determined edits identify the pharmacies and specific claims
for desk review. The initial investigations are identified through
the results obtained when we submit a client’s claim data to the
rigorous system review using the AudiTrack© application.
The Pharmacy Desk Audit Program is utilized in instances where
the system identifies a data trend potentially fraudulent or
abusive in nature or where the claim volume of a specific
pharmacy is not sufficient to be included for an on-site audit.
Overall, we provide our clients with approximately 10% to 20% of
the total audits completed as desk audits. The Desk Audit Program
does not preclude the continual and systematic review of claims
for inclusion into an On Site Audit.
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