Systems and methods for auditing fee calculations associated with claim reimbursement from pharmacy benefit management services

Abstract

Systems and methods for auditing claim reimbursement transactions to ensure that pharmacy benefit management services (PBMs) are properly calculating the appropriate spread values and honoring existing contractual obligations with health plans and/or employer groups. When a discrepancy has been detected and is larger than preset tolerance parameters allow, the adjudicated claim will be sent to the corresponding PBM for explanation of the discrepancy and/or corrective action. Example embodiments of the auditing process may analyze transaction data in batch form, or in alternative embodiments of the invention, the adjudicated reimbursement claim transactions may be audited in real-time or near real-time.