Today, pharmaceuticals are among the fastest growing services within Medicaid, and prescription drug expenditures are higher than ever. To combat rising costs, HMS offers a full suite of pharmacy services, including Pharmacy Audits, a powerful solution to help payors control pharmacy costs and ensure compliance.
In 2008, HMS acquired Prudent Rx, a pharmacy audit and prescription management company, to broaden HMS’s Rx Integrity Services to State Medicaid managed care organizations, Pharmacy Benefit Managers (PBMs), self-insured employers, Third Party Administrators (TPAs), pharmaceutical manufacturers, and others that provide or support pharmacy benefit programs.
Our audit services are robust, and are most effective as an integrated tool set. They include:
- Pharmacy Audits, a critical part of any program, Pharmacy Audits may be the only safeguard against pharmacy fraud, billing errors, and patient/physician abuse. HMS audits 100% of claims via desktop, and selectively chooses claims for on-site audits. If warranted, we perform three-to-four-day focused reviews. We are the only company that intervenes directly with pharmacists in real-time before a claim is paid to reduce the risk of future audits.
Our Pharmacy Audits provide recoupment of payments, provider education, fraud detection, and fraud deterrence. They can be customized to meet client needs, ranging from simple, routine credentialing audits to desktop programs that use the latest database and modeling technology. - Pharmacy Benefit Manager (PBM)/Claims Processor (CP) Audits, which examine and evaluate the operations and procedures of the PBM/CP. PBMs/CPs handle millions of claims in real time without manual intervention. Errors in this process can cost health plans billions of dollars.
As an independent auditor, our clients never need to be concerned about conflicts of interests inherent in processing and auditing the same claims. Our PBM/CP Audits ensure accurate administration; establish performance benchmarks; and educate PBMs/CPs on expectations for administration. - Rebate Audits, which assist in ensuring that a sound and timely rebate process exists. We examine and evaluate the operations and procedures of the PBM/CP to verify the accuracy of a client’s Rebate administration, establish performance benchmarks, and educate the PBM/CP as to the client’s expectations. Our system of checks and balances ensures adherence to rebate contract guidelines, which have grown more complex in recent years.
From a financial perspective, HMS can help to ensure that rebates on claims with billing or adjudication errors are minimized. From a clinical perspective, we can help identify areas where rebates are being applied to prescription claims outside the normal guidelines.
We have over 500 physicians, 300 RNs, coders and pharmacists and experts in DME and dental on staff.
