Contract Audit Necessary to Ensure Integrity of PBM Contracts

Pharmacy Benefit Managers

Pharmacy Benefit ManagersPharmacy benefit managers (PBMs) have become one of the fastest growing businesses in the United States as the number of Americans relying on prescription-drug benefits continues to increase. According to Kaiser Family Foundation, people in the United States have been allotting more budgets for prescription drugs since 1990.

Spending for prescription drugs and, or PBM contracts increased to $216.7 billion in 2006, five times higher than the recorded spending in 1990. A study by the Centers for Medicare and Medicaid Services of the National Health Statistics Group, meanwhile, revealed that prescription spending might increase twice as much as the record in 2006 by 2018.

With these data, regulators and experts are also expecting to see a sudden surge in the number of companies, government organizations and even individuals acquiring PBM contracts.  Regulators, however, advise companies and individuals to ensure the integrity of their PBM contract, noting that only effective policies help in saving money while maintaining guaranteed health plan for members.

According to them, hiring the services of third party consultants or auditors is important to review and verify the terms of a PBM contract. Since state legislatures are also requiring PBMs to be transparent in all their business practices, acquiring a PBM audit system like one from would support the call for PBM contract transparencies.

A PBM audit system will help clients or plan sponsors evaluate the services that they are getting, as well as review costs and quality.  PBM auditors conduct a thorough assessment of accuracy and timeliness of cost controls, systems, and procedures; management information; and payment claims and rebates.

The auditors are also studying the PBM organization’s internal controls. A PBM audit system must also help plan sponsors in determining if they are getting the best financial arrangements. Most of all, PBM auditors will help in identifying, or resolving if there is, any errors in the PBM contract and claim-adjudication process.

Clients and/or plan sponsors should also remember that it is important to determine if the PBM includes auditable and sustainable terms in the contract, such as transparency and fiduciary responsibility. Remember that the clarity of the contract terms is important in ensuring the integrity of the PBM contract.