RxAnalyzer™ provides two modes of service:
- Retrospective Analysis – analyzes historical claims as far back as
six years
- Prospective Analysis –
analyzes current claims and provides results, within minutes of upload, to
verify invoices prior to payment
Retrospective Auditing
Retrospective auditing allows RxAnalyzer™ to look at your billing from the past
and generate reports to show where you were over-charged for claims. These
reports can then be used to recover those charges from your PBM.
Prospective Auditing
Prospective auditing services allow you to keep constant tabs on your PBM.
RxAnalyzer™ can look at your bi-weekly claim reports and find where you’ve paid
too much. These reports can show how much you really owe your PBM so that you
don’t keep overpaying with every bill. Include the reports along with your
payment for the proper amount in order to prevent paying too much.
We accomplish these audits by having the PBM company at your direction, or you,
import the monthly current claims history into our pharmacy audit and tracking
database. Our program traces each adjudication back to an individual
prescription number and dispensing date. There is no extrapolation of claims
made with our program, each claim is examined for compliance.
RxAnalyzer™ uses custom reports to quickly
and accurately outline overcharges and mistakes by your PBM.
Client Profile:
To provide a breakdown of all the contractual terms and
rates pertinent to the pharmacy claims analysis. Every RxAnalyzer report is, in
part, contingent on the values identified on this report. These values are
typically pulled directly from the Client’s (a.k.a. “Sponsor” or “Payor”) PBM
Agreement.
Claim Summary:
To categorize and account for each and every claim record within the claim file provided
by the PBM. The report is divided into two main groups - Retail Claims and Mail Order Claims.
Price Summary:
To generate a price summary, for the claim period specified, that will identify drug
utilization costs within specific claim categories.
Ingredient Cost Discrepancy Summary:
To generate a summary analysis, for the claim period specified, of the pharmacy claims
identified as having an overcharged ingredient cost. Claims that did not
meet the minimum ingredient cost discount rate required by the terms of the PBM contract are identified as overcharged.
Ingredient Cost Discrepancy Detail:
To generate a detailed analysis, for the claim period specified, of the pharmacy claims
identified as having an overcharged ingredient cost. Claims that did not
meet the minimum ingredient cost discount rate required by the terms of the PBM contract are identified as overcharged. Each
overcharged claim is presented on this report with sufficient data to challenge the PBM.
