Process and Claims Audit

IndustryManaged Care/ PBM
ProblemThe PBM was preparing for an upcoming audit from an important client that was looking to validate that the PBM is compliant with the terms and performance guarantees specified in the client agreement. The PBM requested that PHSI conduct a pre-audit of the client's agreement to prepare the PBM for the upcoming audit.
PHSI SolutionPHSI examined a year's worth of data to conduct a claims audit, reviewed the terms of the agreement including performance guarantees, and conducted interviews with PBM management to prepare the PBM for the client’s auditors. As part of the process and claims audit, PHSI analyzed the PBM’s process and procedures and made recommendations for operational improvements.
ResultsThe PBM was well prepared for the client audit and passed the review with outstanding results. The project provided a risk mitigation strategy by equipping the PBM with the knowledge to successfully navigate the client’s audit while improving its operational processes.