PBM Auditing Services
from Pinnacle Risk Solutions
Professional Expertise Across the Dataset
Modern database technologies have made outdated sample-based audits a thing of the past, yet many PBMs resist transitioning to comprehensive validations.
Pinnacle Risk Solutions is helping organizations across the country change this dynamic. With pharmacy transactions often trailing other industries in accuracy, systematic and electronic audits have become invaluable for identifying and correcting errors.
Our robust approach delivers precise results, regardless of the size of the claims file.
Claims Audit
- Duplicate Claims
- No Discount
- Eligibility
- Multiple Procedures
Performance Audit
- Effective Discount Analysis
- Specialty Drug Analysis
- OTC Opportunities
- Top 25 Pharmacies
- Maintenance Drug Analysis
RFP Support
- Medical Claims Re-pricing
- Facility Utilization
- Vendor Analysis
PBM RFP Submission and Analysis 3 Phase Approach
Pinnacle Risk Solutions works with the needs of each client. The scope, timeline, and analysis of the RFP can be customized to meet your organization’s specific needs. Our Standard “Best Practices” PBM RFP Submission and Analysis service comprises three phases.
Phase I
Pre-RFP Analysis
Prior to the issuance of a comprehensive pharmacy benefit RFP, we will carefully provide the following services to aid in the development and potential release of your PBM RFP.
1. Comprehensive Pharmacy Claims Audit
Pinnacle Risk Solutions audits a minimum of 12 months of pharmacy claims data from the current pharmacy benefit manager. Once received, Pinnacle Risk Solutions will verify existing PBM terms and conditions including:
- Contract Language Review
- AWP Discounts (Retail, Mail, Specialty)
- Drug Classification (Medispan vs. Current)
- Dispensing Fees
- Rebates
2. Current Market Analysis
Pinnacle Risk Solutions will provide a Current Market Analysis using recent PBM terms offered for similar-sized employer groups. That analysis will include:
- AWP Discount Guarantee Comparison
- Rebate Guarantee Comparison
- Specialty Discount Guarantee Comparison
- Potential Savings Analysis
Phase II
RFP Preparation, Submission and Analysis
Utilizing the data provided in Phase I, we will establish and release a comprehensive PBM RFP to qualified PBMs, ensuring accurate vendor comparisons.
1. Request for Proposal Components:
- Detailed Questionnaire
- De-identified Claims Repricing Request
- PBM Contract Language Requirements
2. Request for Proposal Evaluation Components:
- Summary of Questionnaire with Comments
- Summary of Claims Repricing
- Summary of Savings Projections
Phase III
PBM Performance Verification
Six months after implementing a new PBM agreement, claims data will be reviewed to ensure the PBM’s performance aligns with contracted terms:
- Actual Achieved AWP Discounts
- Pursue Recovery
- Rebates Achieved
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