Pharmacy claims audits focus on prescription drug pricing, rebates, and utilization, while medical claims audits evaluate billing accuracy for drug-related medical procedures and infusions.
You Can’t Optimize Your Plan Without Key Insights
With drug costs continually rising, we understand you need detailed insight into pharmacy claims and benefit spending to drive smarter financial decisions.
Our pharmacy management consultants perform independent, specialized PBM clinical audits and annual reconciliations that help plan sponsors verify, optimize and protect their plan’s performance. We go beyond standard reviews to enhance transparency, drive cost savings, and identify noncompliance issues through comprehensive medical claims audits.
Annual Reconciliation Services
That Ensure PBM Accountability
Every client receives full pharmacy and medical claims audit flexibility without PBM restrictions.
Our annual reconciliation offers the same insights as traditional PBM audits but with no hidden fees, fine print, or roadblocks. We deliver a transparent, contract-aligned review of financial performance that drives cost savings and gives you greater control over ROI.
Our PBM clinical audits and annual reconciliations independently confirm:
- Pricing and rebate guarantees
- Claims Audits
- Rebate Audits
- Network access and specialty drug adherence
- Service-level performance and penalties owed
Independent Audits for Pharmacy and Medical Claims
We’ve designed our independent pharmacy claims audits and medical claims audits to uncover cost discrepancies and contract violations that PBMs often overlook – or intentionally obscure.
We operate without influence from third-party administrators or PBMs, giving you a clear, unbiased view of plan performance.
By applying clinical rules and deep contract expertise, we identify billing irregularities and ensure compliance with negotiated terms. At the end, you get stronger oversight, measurable savings, and total audit transparency.
Real-Time Insights With PharmaSight™ Analytics Platform
We combine clinical expertise and proprietary analytics to deliver smarter pharmacy claims audits and medical claims audits that drive cost savings, reduce risk, and improve plan performance.
Our analytics engine, PharmaSight™, processes prescription claims data alongside trusted third-party sources like MediSpan and NCPDP DataQ. This ensures consistent drug classifications across brand, generic, and specialty prescriptions, and supports accurate, rule-based audit findings.
When PBM clinical audits reveal discrepancies between reported outcomes and actual claims data, we identify and recover missed savings for our clients.
With PharmaSight™, we provide:
- Real-time performance monitoring across financial, clinical and contractual metrics throughout the year
- Trend detection to identify shifts in utilization or cost drivers
- Data-driven recommendations for formulary and program optimization
Together, these insights empower plan sponsors to make proactive, data-driven decisions that strengthen oversight and maximize the impact of their pharmacy and medical claims audits.
Ready to Lower Your Pharmacy Benefit Costs? Book a Free Strategy Session Today
Partner with Innovative Rx Strategies to learn how our independent PBM audits can reduce costs, improve compliance, and give you full visibility into your pharmacy benefits.
Contact Our Experts TodayPBM Clinical Rule Audit FAQs
How often should we conduct PBM clinical audits?
We recommend conducting PBM clinical audits annually to ensure ongoing contract compliance and to catch pricing discrepancies before they impact your bottom line.
Can pharmacy claims audits help identify specialty drug overspending?
Absolutely. Our audits analyze specialty drug claims to uncover excessive costs, off-label usage, and missed opportunities for savings based on clinical guidelines.
Are medical claims audits useful for self-funded employers?
Yes! Medical claims audits help self-funded employers verify claim accuracy, detect overbilling, and ensure adherence to negotiated terms with PBMs and TPAs.
Our Results and Insights
- February 14, 2025
Fiduciary Responsibility
Read MoreFiduciary responsibility in pharmacy benefits is under increased scrutiny due to lawsuits alleging mismanagement and inflated drug costs. Employers must proactively manage pharmacy benefit plans by understanding PBM contracts, conducting audits, leveraging independent clinical expertise, and optimizing plan design. Key …
- June 15, 2023
Regional Utility Company Saves Over $14M on Pharmacy Benefit
Read MoreA partnership with Innovative allowed the client to maintain a rich benefit for their employees while saving over $14 Million.
