Financial Audits

Solutions

Perhaps the most critical part of the analytical services Caribou offers clients is the ability to identify the value of their PBM’s claim processing through our re-pricing analysis. The PBM industry is notorious for fine print, caveats and exceptions that can dilute or distort the actual value of proposed and implemented pricing terms and claims payment administration.

Caribou’s extensive experience in auditing millions of claims over the past 10 years gives us insight into many of the unique algorithms and financial methodologies at play in the PBM industry related to contracting strategies. This background helps us effectively translate contract terms into concrete rules for our audit system and report the value of each term in a simplified format to support your decision-making opportunities.

In addition to the standard annual discount and dispensing fee determinations, reporting options include the following reviews:

  • Mid-year pricing improvements
  • Mid-year postage increases affecting mail order dispensing fees
  • Lower of Usual & Customary (U&C) pricing
  • Minimum discounts applied
  • Duplicate claim payments
  • Inaccurate Average Wholesale Price (AWP) basis
  • High dollar claims, including compounded products
  • Specialty drug re-pricing
  • Client invoice validation

CARIBOU FINANCIAL AUDIT ADVANTAGES

  • The CRx system re-prices 100% of paid claims data.
  • Financial reporting breaks out results in over 100 sub-categories to confirm whether the PBM met the obligations of the financial contract terms.
  • Financial shortfalls and surpluses are reported for all sub-categories to provide details of how each of the financial contract terms is working for or against you in annual performance guarantees.
  • Caribou’s financial audit staff is well versed in PBM contract language and can ensure that PBM financial reporting accurately and fairly represents the terms outlined in the client’s contract.
  • Caribou maintains a database of drug classification and clinical attributes to validate PBM reporting drug prices along with other financial metrics.

For more information about how we can help your organization,
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