PHARMACY BENEFIT COMPLIANCE AND CONTRACT PERFORMANCE AUDITS

Myers and Stauffer has extensive national experience performing pharmacy compliance and contract performance audits for the Medicare program and for State and local government entities. We have performed over 300 pharmacy compliance and contract performance audits exclusively for governmental entities. Our governmental pharmacy auditing expertise includes:

  • Performing pharmacy claims audits to assess contractual adherence and accuracy regarding contractual discount rates, unit price basis, dispensing fees, copayments/coinsurance rates, deductible accumulation, benefit design adherence and plan limits.
  • Performing drug rebate audits to ensure accuracy and completeness of drug rebate offsets including analysis of ineligible claims, drug manufacturer contracts, Wholesale Acquisition Cost (WAC) basis, base/ incentive/ performance-based rebate components and market basket calculations.
  • Conducting audits of drug formulary administration includingbenefit provision adherence to program guidance and approved drug formularies, adherence with new and continuing beneficiary transitional drug benefit administration, accuracy of plan sponsor formulary website information, and adherence with Pharmacy and Therapeutics Committee membership requirements.
  • Conducting reviews of policies and procedures surrounding coverage determinations, appeals and grievances including verification of coverage determinations, redeterminations, and externally reviewed cases where delays in access could have adverse health outcomes; clinical decision making to ensure timeliness as well as clinical compendia adherence; and grievance administration and resolution.

We have reviewed pharmacy benefit plans of all sizes and in all geographic regions across the country. Our experience includes benefit plans ranging from 100 members to plans with over one million members and includes auditing the benefit management practices of the largest Pharmacy Benefit Managers (PBMs) in the industry. Our experience provides an extensive understanding of the complexities of the pharmacy benefit industry and regarding the business practices of plan sponsors and their PBMs.

Our pharmacy benefit audit experience includes procedures designed to ensure the accuracy and completeness of plan sponsor financial reporting as well as to ensure program beneficiaries receive proper access to care as defined by regulatory and program guidance. Whether you are interested in assessing contract compliance for your third party administrator or assessing regulatory compliance of your managed care organizations, the depth of our pharmacy benefit audit experience will help you accomplish your goals.

SELECTED CLIENTS
Center for Medicare and Medicaid Services (CMS)

Texas Health and Human Services Commission

Lower Colorado River Authority

City of Wilson, North Carolina

Montgomery County, Maryland

FOR MORE INFORMATION
PH 800.374.6858