Innovation during pandemic results in successful virtual pharmacy audit program
Challenge
Pharmacies play a critical role in keeping communities healthy. When the COVID-19 pandemic hit, pharmacies needed to take special measures to protect their customers and staff, including limits on who was allowed onsite. These adaptations impacted pharmacy audits, which are essential to cost containment, overpayment identification, and compliance.
In 2020, our client, a large national pharmacy benefit manager (PBM), came to us looking for a way to conduct pharmacy audits in light of the COVID-19 restrictions. In addition to pharmacy limitations on in-person visits, auditors also faced travel barriers.
Human ingenuity
As a flexible and collaborative partner, EXL’s pharmacy leadership team quickly worked to develop a virtual pharmacy auditing process. Our program leverages a telephonic interview and approval process, and collects required documentation (including relating to licensure, proof of training, employee verification against the OIG exclusion list) virtually and then uploaded to an SFTP portal. Audits of claim are conducted at desk.
Beginning in August 2020, the EXL pharmacy team resumed their audits on a virtual basis satisfying the client’s onsite audit requirements. EXL initiated over 3,400 such audits in the last five months of 2020, completing all required audits, and satisfied all client audit needs, ensuring pharmacy compliance as well as preventing erroneous billing during the COVID-19 public health emergency.
During this same time, the client also came to EXL, as a trusted partner, when they were facing another challenge: a rule change from one of their clients that prevented certain audits that were previously conducted and caused a significant, multi-million dollar loss in revenue for the client. After discussion and solutioning, our client implemented EXL’s Prescription Verification Review (PVR) program, a process that reviews individual claims that are high risk and meet certain dollar thresholds, regardless of the specific pharmacy that submits them. Combining daily client claim feeds with selections using EXL’s proprietary algorithms, and our deep domain expertise, our process ensures that the best claims are selected and progressed through the auditing process. Once the audit has been conducted, EXL communicates the findings to the pharmacy and sends the results to our client for re-adjudication. EXL was able to quickly implement this program, with high quality levels, to address the client’s substantial revenue loss.
Results
Our two auditing programs were a success, with both EXL Health and our client concluding the new virtual onsite process as well as PVR audits win/wins.
As an additional benefit of the virtual pharmacy audits, which were not limited by geographic restraints and therefore more efficient, the resulting findings per audit increased in 2020. Our client was also able to guarantee more audits for its individual clients, as scheduling constraints were a nonissue. While the client resumed some onsite pharmacy audits in June 2022, they’ve seen the value in the virtual pharmacy audits and have made the decision to maintain a hybrid approach, leveraging a combination of both onsite and virtual auditing activities.
Our second solution, EXL’s PVR program, provided significant net findings, resulting in an ROI of over 80%. In 2023, based on this success our client will increase the volume of such audits by 28.5%.