Various businesses deal with pharmacy benefit management (PBM) companies to cover their needs. PBMs administer drugs prescribed, on behalf of plan sponsors as a component of health insurance plans.
These plan sponsors include insurance companies, health maintenance organizations (HMOs) and self-insured employers. Their primary goal of PBMs is to provide top notch drug care at a reduced cost. They may have other additional services and functions such as:
- Improvement of pharmacy networks;
- Disease management programs;
- Formulary management;
- Generic drug substitution;
- Rebate negotiations between drug manufacturers;
- Prospective and retrospective DURs or drug utilization reviews.
Even with these and other benefits, there is still a need to examine the effectiveness of a PBM, notes Crystal Clear RX. Even a small mistake may result in a large number of incorrectly paid claims.
Typically, a comprehensive audit system of a PBM includes electronic testing of the available claim data, subsequent to a manual evaluation of claim issues from flagged electronic testing. It also examines plan designs, financial elements, rebates, claim eligibility, as well as performance guarantees. The return on investment of the audit is considerable, which is why it is valuable for those who use PBMs.
7 benefits of hiring a PBM consultant
1. Cost Savings
Your organization can enjoy substantial cost savings on annual drug prescriptions. With a detailed analysis of factors such as clinical programs, specialty drug management, and formulary management, you will get the lowest cost possible.
2. Full Transparency
There is a clear agreement between you and the consultant with flexible, fair and auditable contract terms.
3. Professional Industry Executives
You will have the chance to work with managers, clinicians, and analysts to meet your needs.
4. Proactive Plans and Programs
Your organization will have an appropriately-designed plan at the best price. This lets you stay ahead of the changes in the PBM industry.
5. Customized Audit Reports
You will get consistent and timely performance reviews with detailed reports.
6. Clinical and Financial Benchmarking
Working with experienced PBM consultants gives you the chance to enjoy the benefits that other similar organizations have.
7. Readily Available Collective Option
For plan sponsors, collective purchasing is becoming the norm. A PBM consultant can get you into this as well.
Without proper auditing, even the best PBM will have errors. It is essential to have a reliable consulting firm that works to improve your dealings with your PBM.