In 2023, the pharmacy benefit management (PBM) industry witnessed a significant shift in client sentiment. Health plans, employers, health systems and unions reported a notable decrease in satisfaction with their PBM vendors, as detailed in the 2023 Pharmacy Benefit Manager Customer Satisfaction Report by Pharmaceutical Strategies Group (PSG).
The Kraft Heinz Company is currently amid a $1.3 billion legal battle with one of their key healthcare vendors responsible for managing their medical benefit. More specifically, the lawsuit claims the medical benefit vendor “paid millions of dollars in provider claims that should have never been paid dating back to 2012.” While the case specifically pertains to the administration of the medical benefit, many parallels exist with the pharmacy benefit landscape at large.
In this article, HealthPlan Data Solutions’ (HDS) claims analysts will review the purpose and limitations of traditional PBM audits, offer insights to help health plans establish robust pharmacy payment integrity programs, and provide suggestions to enhance accountability in the pharmacy benefit.
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HealthPlan Data Solutions Clinical Pharmacy team discusses five best practices to improve payer campaign management strategies and drive improvement of key quality measures.