TRICAST Over the Counter

A standard TRICAST audit re-adjudicates 100% of all claims data—not just a sampling—using TRICAST software that mimics the original claim adjudication. We don’t stop at just the paid claims either, because we also include the “raw” claims transactions in our analysis. We feel that the addition of this raw data is critical to our understanding of claims processing accuracy, and it helps us create a platform for rapid resolution and recovery. It’s typical for us to find a 1% variance that can represent (depending on the type of variance), up to 3% of the total cost.

Statistical sampling is okay, but…

It’s long been our position that, while statistical sampling can provide a fairly decent overall view of a point-of-service system, such a small claim sample would not likely detect the 1% variance I mentioned above. For example, if the sample doesn’t include compounded claims, criteria for considering Dispense as Written (DAW) strategies on copay algorithms, or the types of pharmacies submitting claims, the report could provide a less than accurate view of the program.

Accurate assessment of all plan design attributes and the appropriate forensic analysis of the claims and eligibility are essential elements that only a full review can provide. Accordingly, every one of our reports is driven by actual claims re-pricing, not summary reports, with simple discounts and arithmetic applied. Only by re-adjudicating 100% of the PBM’s claims can we review and benchmark variances.

What makes our audits so special?

What else sets a TRICAST audit apart from statistical sampling audits? Take a look:

• We load 100% of the claims for each of our clients and conduct a thorough analysis using fixed files, including both Medi-Span® and First DataBank, to identify the correct attributes of every claim
• We utilize proprietary algorithms to identify that the appropriate identifiers, claims status, and prescribers that are being used on each claim
• We consider all claim attributes to ensure the accuracy of the audit report. This approach is unique and driven by our sole focus on pharmacy claims data. We review over 100 independent claim attributes, such as:
  • Basis of cost status as a paid, reversed, adjusted or rejected claim
  • Claim source as defined as a pharmacy transmitted claim, a batch claim, or manual subscriber submission
  • Correct status of the paid claim, consisting of all positive values

Benchmarks are a by-product

A by-product of our 100% evaluation is a comparative analysis of pricing and contract parameters that enables us to benchmark potential rebates to be considered by the person responsible for oversight of the program.

It’s what we do best

Will TRICAST do statistical sampling? Sure, we can do it, and do it very well. However, we will always recommend doing the full 100%. Not some of the data, not even most of the data. One hundred percent is what we do best, and it’s what sets us apart from everyone else.

[By Greg Rucinski, President and CEO]