In 2019, PillarRx was awarded this audit project for a federal insurance provider. The scope of work included a pricing audit, plan design audit, and fraud, waste, and abuse review. This 100,000-life group offers multiple prescription plans across Medicare and Medicaid Programs. Following the initial audit findings, PillarRx uncovered several drugs within the formulary that were mis-adjudicated throughout the 12-month audit timeframe. The PBM was notified of the errors and agreed to a reimbursement of $161,000 back to the client. The provider also performed their own internal audit of the PBM and discovered a misapplication of their formulary. PillarRx worked with all parties to ensure these plan design errors had been corrected. Additional audit services are ongoing in 2020.
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