Independent Auditing & Consulting Services
Prescription Drug Event Audit
Medicare Part D plan sponsors typically rely on their PBM to submit Prescription Drug Event (PDE) files to the Centers for Medicare and Medicaid Services (CMS). PDE files are the basis for all federal Part D subsidies. In many cases, there are discrepancies between these files and the claim expenses charged by the PBM to the Part D plan.
TRICAST’s audit process includes an assessment of appropriate calculations and various conditions. The end result of a TRICAST audit is a detailed report listing sample patient records in which TRICAST’s calculations do not match the original PDE records.
Rejected Claims Analysis
Rejected claims monitoring is a vital component of pharmacy benefit manager (PBM) oversight for Medicare Part D plan sponsors, and is a powerful tool for ensuring that the plan membership is receiving the correct medication.
TRICAST reviews rejected transactions, ensuring that the plan management is aligned with appropriate plan design adherence. Our system analyzes your rejected transactions to ensure that the six protected classes are not affected. TRICAST’s thorough analysis will enable you to provide pharmacies with accurate reasons for claim rejections, as well as detailed messaging.
A TRICAST rebate assessment validates rebate calculations and verifies compliance with contractual percent of rebate collection passed through to you.
Rebates are a complex combination of formulary, copay structure and utilization translated into significant monies back to the plan. The dollars negotiated between the PBM and drug manufacturers that are subsequently shared with the client fall under a contractual requirement of confidentiality which necessitates an onsite review of the drug manufacturer rebate agreements.
Medicare Eligibility Audit
The Eligibility Accuracy Audit process includes a full 100% review of all applicable eligibility files such as:
- Monthly Membership Report (MMR)
- Transaction Reply Report (TRR)
- Low Income Cost-Sharing Subsidy (LICS) files
Medicare Data Validation
TRICAST assists and carries the primary responsibility for all phases of the PBM selection process from preparation of the initial RFP to managing and contracting with the PBM. Armed with industry benchmarks plus our risk and underwriting experience for a variety of insurance carriers, TRICAST manages a precise, risk modeled RFP process that leads to accurate contracting and low net cost with the chosen PBM.
Using your plan specific data, we require all potential vendors re-adjudicate your historical claims according to their proposed contract terms and programs. We then conduct an actuarial analysis, determine the potential ROI, and require that the contract match the marketing proposal and claims re-adjudication.
Contract Renegotiation Services
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The Audit Process in a Nutshell
Here’s how we do it.
TRICAST performs audits of Pharmacy Benefit Managers (PBMs) for health plans, state employee programs, Fortune 500 employers, business coalitions, third-party administrators and an assortment of other business entities. Responding to the broad scope and complexity of a typical audit, TRICAST developed software that integrates a robust rules-based reprocessing engine with a unique reporting and communication platform. Here are the analysis and communication processes TRICAST follows throughout a typical auditing project.
How It Starts
A TRICAST audit reprocesses 100% of all claims data with the use of TRICAST’s software that independently assesses the PBMs original claim processing and, in addition to assessing the paid claims, reviews the transactional claims (often referred to as “raw” claims) billing in our analysis.
Transactional claims represent the successive pharmacy provider claim submissions (and associated communication between the PBM and provider) that ultimately lead to an approved paid claim. The addition of this data is critical to our understanding of the PBM’s claims, and helps us create a platform for audit resolution and financial assessment.
An initial verification of the claims and eligibility data submitted for the audit, referred to at TRICAST as the data forensic, are essential elements that ensure validation of PBM performance.
A TRICAST audit also verifies performance through the use of independent data sources, including both Medi-Span® and First DataBank™, to identify the correct attributes of every claim.