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A Pharmacy Benefit Risk Manager (PBRM) identifies and eliminates cost inefficiencies from your employee pharmacy benefit delivery process. Without changing plan design; using techniques transparent to your plan members; PBRMs can find between 7% -10% in cost savings. Types of analysis and services include:
- Claims Paid Outside of Plan Design
- Contract Analysis & Renegotiation
- Eligibility Audits
- Full Claims Sets Audits
- Identification of PBM Inefficiencies & Programming Errors
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- MAC Re-Pricing
- Mail Order Savings Determination
- Plan Design Strategy
- Prospective Savings Opportunities
- Rebate Audits
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As a result of audits, there are several forms of Return on Investment (ROI) you can expect:
- PBM Contract Renegotiation - expressed in two ways: (1) understanding where the current contract is deficient in defining terms and conditions, which, if properly defined would have produced recoveries, and (2) leveraging the audit results to gain more favorable discount and pricing terms. Perfect for your use in contract renegotiation!
- Plan Design Changes - once your data is loaded and analyzed, the PBRM provides precise cost modeling capabilities. The modeling tools are available over the web and can be the same tools used to model and underwrite risk on behalf of insurers and re-insurers.
- Prospective Savings Opportunities - typically 7-10% of annual claims dollars in prospective savings. These savings do not require plan design changes.
- Retrospective Claims Recoveries - or "potential" claims recovery. Whether these claims are recoverable is dependent on a number of factors. The process of "proving" pricing and plan design violations, for purposes of recovery, is a long and arduous process. How, when, and if they are paid is uncertain, usually negotiated, and rarely equal to the amount initially identified.
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