PHARMACY BENEFIT PROGRAM INTEGRITY CONSULTING AND AUDITING

Myers and Stauffer has extensive national experience performing pharmacy program integrity audits and consulting projects for the Medicare and Medicaid programs.Our governmental pharmacy program integrity expertise includes:

  • Performing risk assessments to identify high risk providers and prescribers;
  • Performing pharmacy claims audits to detect potential fraud, waste and abuse;
  • Identifying duplicate claims payments;
  • Identifying claims paid for ineligible patients;
  • Identifying ineligible pharmacy and physician providers;
  • Reviewing claims filled too early for potential stockpiling;
  • Clinical review of excessive quantities, numbers of prescriptions and combinations of therapeutic classes of medications for appropriateness;
  • Identifying outlier patterns of drug usage inconsistent with average utilization;
  • Identifying prescription claims where the quantity of units submitted exceed the package size per drug code;
  • Reviewing gender specific medications filled for the opposite gender;
  • Identification of doctor/pharmacy shopping patterns;
  • Reviewing compound medication charges for appropriateness;
  • Reviewing implementation of preferred drug lists;
  • Reviewing prior authorization policies and procedures;
  • Reviewing secondary payer policies and procedures.

We have reviewed pharmacy benefit plans of all sizes and in all geographic regions across the country. Our experience ranges from benefit plans with 100 members to benefit plans with over a 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 of the business practices of plan sponsors and their PBMs.

Our pharmacy benefit program integrity experience includes procedures designed to identify and deter fraud, waste and abuse within pharmacy benefit programs. Whether you are interested in assessing the adequacy of your program integrity policies and procedures or performing targeted program integrity audits, the depth of our pharmacy benefit audit experience will help you accomplish your goals.

CONTACT

Andy Ranck, CPA

Member

400 Redland Court
Suite 300
Owings Mills, MD 21117

PH 800.505.1698
PH 410.581.4555
aranck@mslc.com