Independent Auditing & Consulting Services

Helping you navigate today’s healthcare environment.

Pricing Audit

In a Pricing Audit, TRICAST assesses your financial performance by performing a detailed analysis utilizing 100% of your pharmacy claims for the audit period. The Pricing Audit includes an analysis of discount guarantees and is designed to thoroughly examine a PBM’s financial performance.

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Rebate Audit

A TRICAST rebate assessment validates rebate calculations and verifies compliance with contractual percent of rebate collection passed through to you.

Rebates are a complex combination of formulary, copay structure and utilization translated into significant monies back to the plan. The dollars negotiated between the PBM and drug manufacturers that are subsequently shared with the client fall under a contractual requirement of confidentiality which necessitates an onsite review of the drug manufacturer rebate agreements.

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Prescription Drug Event Audit

Medicare Part D plan sponsors typically rely on their PBM to submit Prescription Drug Event (PDE) files to the Centers for Medicare and Medicaid Services (CMS). PDE files are the basis for all federal Part D subsidies. In many cases, there are discrepancies between these files and the claim expenses charged by the PBM to the Part D plan.

TRICAST’s audit process includes an assessment of appropriate calculations and various conditions. The end result of a TRICAST audit is a detailed report listing sample patient records in which TRICAST’s calculations do not match the original PDE records.

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Rejected Claims Analysis

Rejected claims monitoring is a vital component of pharmacy benefit manager (PBM) oversight for Medicare Part D plan sponsors, and is a powerful tool for ensuring that the plan membership is receiving the correct medication.

TRICAST reviews rejected transactions, ensuring that the plan management is aligned with appropriate plan design adherence. Our system analyzes your rejected transactions to ensure that the six protected classes are not affected. TRICAST’s thorough analysis will enable you to provide pharmacies with accurate reasons for claim rejections, as well as detailed messaging.

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Medicare Eligibility Audit

The Eligibility Accuracy Audit process includes a full 100% review of all applicable eligibility files such as:

  • Monthly Membership Report (MMR)
  • Transaction Reply Report (TRR)
  • Low Income Cost-Sharing Subsidy (LICS) files

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Medicare Data Validation

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Part C and Part D plan sponsors to undergo annual data validation by an independent third party. TRICAST has the background, expert staff and data analysis tools to meet CMS’ data validation requirements while exceeding your expectations for a comprehensive review, communication throughout the process, and quality results.

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RFP Services

TRICAST assists and carries the primary responsibility for all phases of the PBM selection process from preparation of the initial RFP to managing and contracting with the PBM. Armed with industry benchmarks plus our risk and underwriting experience for a variety of insurance carriers, TRICAST manages a precise, risk modeled RFP process that leads to accurate contracting and low net cost with the chosen PBM.

Using your plan specific data, we require all potential vendors re-adjudicate your historical claims according to their proposed contract terms and programs. We then conduct an actuarial analysis, determine the potential ROI, and require that the contract match the marketing proposal and claims re-adjudication.

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Contract Renegotiation Services

An alternative to a full PBM Request for Proposal (RFP) service, TRICAST’s pharmacy program process begins with a thorough review of a proposed PBM contract. A TRICAST contract review identifies gaps in contract language and financial performance, and provides a focused discussion on establishing new contract terms. Our review team of experienced professionals has completed dozens of contract negotiations for clients of all sizes.

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