Process Improvement

A process improvement audit adds eligibility and Concurrent Drug Utilization to the Contract Compliance Audit and results in savings from retrospective recoveries and identifying where the claims adjudication process has failed or needs to be improved.

When eligibility is integrated with the Contract Compliance Audit, the result is criteria based evidence used to improve almost every PBM process. TRICAST performed a three-year retrospective claims audit and conducted a thorough comparison of the plan sponsor supplied eligibility to the eligibility loaded and maintained by the PBM.

TRICAST found that eligibility checking was only being done on the subscriber number. This resulted in dependent claims being paid post eligibility. The members of this business coalition received almost $1 million in recoveries as well as an accommodation in their PBM contract terms.