Determining PBM Performance Just Got Easier
Relying on your PBM to tell you how well they are performing, isn’t enough to verify that contractual guarantees are being met. They may be living up to contractual agreements, but unless you’re reviewing each and every prescription claim, you can’t be sure.
PillarRx’s PBM audit methodology compares contract terms and service guarantees to actual PBM performance. We provide clients reliable, non-biased results that determine if money is owed back or if your PBM is performing up to contractual obligations. As an independent, third-party PBM auditor, our team of professionals have extensive experience reviewing PBM contracts and leading a thorough review of pharmacy benefit programs.
PillarRx conducts over 200 PBM audits per year utilizing 100% review of your pharmacy claims through our proprietary tools.
We ensure our customers are receiving all of their contractual requirements. We do this through our standard methodology, which is to audit 100% of all pharmacy claims and not a subset or sampling of claims. We have built tools that are proprietary to PillarRx and equivalent to a PBM claims processing software system to be able to re-price claims accurately and accommodate the multitude of plan designs and rules to ensure the most accurate audit results.
PillarRx is an approved vendor of all PBMs. Throughout our company’s history, our factual, non-biased approach has allowed us to work with over 35 PBMs. Our nearly 30 years of combined experience, has helped countless customers maximize their financial outcomes, eliminate pharmaceutical waste and abuse, and increase member satisfaction. We achieve this by providing value-based pharmacy solutions utilizing 100% review of your pharmacy claims.
HERE ARE SOME OF THE AUDIT SERVICES WE PROVIDE:
A History of Long-Term Success
For a business coalition, PillarRx found a $2.2 million shortfall following a pricing audit. This coalition included 42 individual groups, totaling 365,000 members. PillarRx compared the groups commercial line of business contract to PBM pharmacy claim accuracy. Findings showed a shortfall occurred due to incorrect claim adjudication of generic/brand pharmacy claims for retail and mail channels. Findings were shared with the coalition board members and the PBM. Initially, the PBM agreed money was owed, but only agreed to a small portion of actual recoupable money. PillarRx fought on behalf of this client, until the PBM agreed 100% of the initial $2.2 million findings would be reimbursed.
