Our Pharmacy Audit Services use Pharmacy Network Ranking to target pharmacies using sophisticated criteria within a data mining and analysis tool. Xerox targets providers most likely to have engaged in fraud or abuse while minimizing audits of those pharmacies least likely of committing fraud.
Direct Mail Audits select members whose profiles are consistent with those used as unwitting vehicles for pharmacy fraud to receive audit letters. Xerox’ letter explains to the member that a pharmacy audit is in process and asks them to review and verify a list of selected prescription claims that were billed on their behalf. The letter includes full-color images of most prescription drugs billed, so patients can confirm that the drug they received looks like the drug pictured.
Commercial populations respond to our direct mail audits at an average rate of 72%, the elderly respond at a rate of 86%, and Medicaid recipients respond 39% of the time on average.
Desk Audits in Pharmacy Audit Services focus on up to 12 months of claims data for each audited pharmacy. Reviewing the claims of a pharmacy allows auditors to analyze data for trends such as refill-too-soon and potential erroneous billed quantities. When all claims have been examined, a database containing the claims recommended for recovery is generated for the client. From this database, we compile a full report that summarizes the findings of the desk audit process and calculates total overcharges.
Onsite Pharmacy Audits are the next step in the audit process. Providers are selected for an onsite audit based on one or more of the following:
- Evidence of potential wrongdoing
- Client request for on-site visit
- Complaints or “tips”
- Qualitative or quantitative outliers (high position in the Pharmacy Network Ranking)
Xerox draws a sample of 100 prescriptions for review by auditors in each pharmacy audit. Auditors review each claim to assess compliance with the applicable rules, regulations and guidelines set forth by the state and federal governments and payer.