Pharmacy Benefit Management
Model Consulting can help you mitigate pharmacy benefits risk. We deploy software applications to uncover, analyze and report savings opportunities while modeling risk in pharmacy benefit programs. Recommended changes are often transparent to plan members. 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
- MAC
- Re-Pricing
- Mail Order Savings Determination
- Plan Design Strategy
- Rebate Audits
- Prospective Savings Opportunities
As a result of audits and data analysis, there are several forms of Return on Investment you can expect:
PBM Contract Renegotiation – we will help you understand where the current contract is deficient in defining terms and conditions, which, if properly defined, would have produced recoveries. The Audit results will be leveraged 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. 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.
