Systems and methods for auditing discount card-based healthcare purchases

Abstract

An adjudicated prescription claim transaction response is received and includes a total amount paid by the claims processor, a patient pay amount, and the pharmacy's Usual and Customary Charge amount for a product/service. The adjudicated response can be evaluated to determine it was approved/paid and the total amount paid by the claims processor is zero or less. An income audit evaluation may be conducted by comparing the patient pay amount to the Usual and Customary Charge amount. Based on the Usual and Customary Charge amount being less than or less than or equal to the patient pay amount, a reversal transaction can be generated and transmitted to a claims processor computer for adjudication. Further, the adjudicated prescription claim transaction response can be converted from an approved/paid response to (or replaced by) a rejected adjudicated prescription claim transaction response and transmitted to the pharmacy computer that initiated the prescription claim transaction.