The Facts
- Industry: Technology and Engineering
- Pharmacy Claims Reviewed: 800,000+
- Contract Errors Identified: Retail Pricing Guarantee Billing ($1.2M error)
- Solutions: truAudit, truGuard
The Problem
Through Truveris truGuard claims oversight, a global technology and engineering company uncovered discrepancies in their PBM reports impacting a significant amount of drug spend being billed by their PBM.
Truveris, in collaboration with the client, built a case using the truGuard oversight report findings and raised the issue with the PBM. The PBM, confident in their reporting, requested a formal audit from Truveris to resolve the issue.
The Approach
In partnership with the PBM, Truveris conducted an in-depth analysis of more than 800,000 claims from across a full contract year.
Leveraging truAudit, the analysis was intended to look for adjudication errors and confirm guarantee calculations from the PBM, including contract terms and variables such as:
- Accurate discounts
- List pricing
- Usual & Customary pricing logic
- Dispensing fees plus guarantees
- Ingredient costs plus guarantees
Initially, the audit confirmed no errors in the review of claim-level pricing guarantees. However, discrepancies were found in the evaluation of aggregate guarantees, where Truveris identified a methodology error for a category of retail claims.
The Results
After the conclusion of the formal audit, the PBM confirmed the audit findings of the uncovered methodology error. The PBM agreed to correct their reconciliation report with the impacted claims moving into the expected guarantee category, per the contract. This resulted in a guarantee shortfall increase of $1.2M for the affected contract time frame.
Thanks to comprehensive claims support powered by truGuard and truAudit, Truveris helped the client identify financial discrepancies and advocated on their behalf throughout the completion of a formal audit review and recovery of funds through corrected claims reconciliation.
Truveris is a pharmacy cost containment company dedicated to reducing pharmacy costs and driving transparency for employers and benefit consultants. Our proprietary, data-driven technology and deep industry expertise empower smarter pharmacy benefit decisions through contract optimization and PBM oversight. Independent and unbiased, Truveris delivers measurable savings and accountability across every pharmacy program.
