Any behind-the-scenes business practices of Pharmacy Benefit Managers (PBMs) can put Group Health Plan (GHP) sponsors and their executives in ever-greater legal jeopardy. The recent tightening of legal and regulatory requirements directly targets increasing transparency in PBM operations.
Anyone involved in health care plans and payments today is aware of the growing number of fiduciary breach lawsuits, some of them sprawling class actions. Each new one reminds corporate plan sponsors about the value of medical and pharmacy claim auditing.
Anyone having anything to do with the U.S. healthcare system would love to hear good news about healthcare pricing and billing. But so far, none appears to be on the horizon. Instead, there is a steady drumbeat of news about a lack of accountability and trust. Everyone agrees there is a problem, but the solution(s) remain elusive. It puts employer-sponsored health plans in an incredibly tough position.
Higher prescription costs and the need to reduce them are driving shake-ups in the PBM landscape. Today, we see an increasing number of health plans changing or questioning their pharmacy benefit managers (PBMs). In every case, there is a vital role to play in a thorough Request for Proposal (RFP) evaluation and negotiation, followed by Rx claim auditing and continuous monitoring. CONTINUE READING
The value of medical claim auditing for self-funded health plans is affirmed in many ways each year – it always pays to review what’s happening with your third-party processor. The latest example to make TPA oversight a topic in the news is a class-action lawsuit filed against UnitedHealthcare Group (“UHCG”) over out-of-network payments. The giant health carrier (and claim processor for self-funded plans) is accused of systemically underpaying benefits for out-of-network claims in violation of ERISA’s fiduciary obligations.