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Audit
Many organizations, including a wide array of accounting firms, offer audit services to the health care industry. These organizations may also have experience in auditing medical claims on behalf of health plans, and may be considerably larger than APC. However, in-depth knowledge of the PBM industry and access to independent drug pricing files are essential for effective assessment of pharmacy benefit programs. In the United States, there is no company that offers greater experience or expertise in assessing pharmacy benefits than does APC. We focus on one thing and we do it very well.
Advanced Pharmacy Concepts has conducted audits of over 20 PBMs nationally during the past several years, including providing an extensive audit of a PBM’s services on behalf of a major international employer. Unlike many audit firms, APC is an approved auditor for every major PBM in the nation, including conducting audits of PBM contracts with manufacturers for rebate administration.
APC’s audit services include:
- Mail and retail pricing compliance with contract terms
- MAC and FUL pricing performance
- Benefit design accuracy
- Therapeutic interchange performance
- Rebate administration accuracy
- Mail order operations
- Workers compensation program management
- Retirement Drug Subsidy management
- Medicare PDE reconciliation accuracy
- Compliance with performance guarantees
- Pharmacy Network oversight assessment
- Medicare COB compliance
- Specialty, home infusion and LTC pharmacy
- Fraud, abuse and waste assessment
APC maintains state-of-the art data analysis systems for use in evaluating pharmacy claims data. Unlike many auditing firms that rely on PBM financial records and reports for auditing purposes, APC’s auditing procedures are designed to re-create the actual services that are provided by the PBM by using independent and verifiable resources for drug pricing, utilization, and contract performance. We subscribe to national drug pricing services for verification of drug prices, therapeutic classifications, and generic/brand determination – all factors that are critical when assessing drug benefit and rebate management performance.
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