Health plan sponsors have the fiduciary responsibility to ensure that their plan members are not being overcharged for prescription benefits. This is a constant and perpetual responsibility since each invoice that comes from the PBM is vulnerable to inaccuracies given the complex contracts that exist between PBMs and payers. While some sponsors may conduct yearly retrospective audits, the real value comes from the ability to seamlessly review your prescription claim invoices.
It is very important to recognize that reviewing an invoice is not the same as performing an audit. A review allows plan sponsors to pay only for accurately-billed claims – the way it should be. We can all agree that plan sponsors have an undeniable right to their full prescription claims data and supporting pricing lists with each invoice they receive – why wouldn’t one be allowed to review a bill before paying it? While it is understandable that contracts may limit audits to once per year, plan sponsors have the right to review their pharmacy bills on an ongoing, regular basis.
Truveris is working with a global investment bank whose head of HR precisely captures this fundamental right and responsibility, as outlined in a response to the company’s PBM:
“At the end of the day, this exercise is considered a ‘bill review’ and not an audit. We have the right to review our bills to determine if we are paying the appropriate amount. Considering how much employees pay for the benefits, we have a fiduciary responsibility to ensure that we engage continuous quality improvement and expense management.”
–Managing Director, Global Investment Bank
In an era of Medicare Part D and coinsurance, it is critical for payers to understand their fiduciary liabilities. Performing an ongoing bill review is the only way to ensure plan integrity.