ClaimSecure’s on-line, real-time drug adjudication system performs an electronic audit on every claim that enters our system.

In addition, we perform random claims verification and on-site pharmacy audits to verify the integrity of prescription claims.

ClaimSecure has several quality-control mechanisms in place that ensures drug claims integrity and monitors abuse and misuse.

• Pharmacy audit of compound claims
• Pharmacy audit of “No Substitution” claims
• Pharmacy audit of reimbursement claims
• Monthly pharmacy statistical analysis
• On-site pharmacy audits
• Member validation of receipt of medications

Verification of compound claims
Currently, under the CPhA version 3, pharmacists are not required to send the list of ingredients used in a compound claim electronically. To verify these claims, ClaimSecure randomly selects 1% of its compound claims each month, requesting the pharmacist to submit the ingredients required in the compound. ClaimSecure ensures that the active ingredient is covered by the Plan. In addition, ClaimSecure ensures that the compounding fee and the time charged for the particular compounded medication is appropriate based on its pre-determined guidelines. For further detail on the compound criteria, click here.

Verification of “No Substitution” claims
ClaimSecure allows payment of brand name medications for those clients that have elected a generic plan when the prescribing physician indicates in writing “ No sub” or “No Substitution”. A random selection of 1% of “ No Sub” or “No Substitution” claims is performed each month. The pharmacy is requested to submit a copy of the original prescription to ensure that “ No sub” or “No Substitution” was prescribed in the physician’s handwriting.
If the original prescription does not have “ No Sub” or “No Substitution” prescribed in the physician’s handwriting, ClaimSecure will adjust the payment based on the lowest generic interchangeable equivalent.

Verification of reimbursement claims
ClaimSecure audits all member reimbursement claims whose value exceeds $1000 prior to sending the payment to the member.

For claim values exceeding $1000 but less than $2500, a ClaimSecure Reimbursement Representative must contact the pharmacy to verify the prescription. For claims whose value exceeds $2500, a ClaimSecure Reimbursement Representative must contact the pharmacy and the prescriber to verify the claim.

Monthly pharmacy statistical analysis
The Pharmacy Exceptional Activity Report (PEAR) evaluates key parameters for each pharmacy that submits greater than 100 claims per quarter. Actual activity of each pharmacy is compared to the average standard performance. Variations are identified and a composite rating is used to identify pharmacies with exceptional activities, for which further investigation may be required.

The PEAR reporting system can accommodate changes in criteria and can be modified to incorporate weighting for factors of highest concern. ClaimSecure makes these modifications to keep in line with the ever-changing practices in our health care system.
Upon completion of the preliminary review, some pharmacies are targeted for further evaluation.

On-Site Pharmacy Audits
Prior to on-site auditing, a systematic review of the pharmacy claims history is performed. Claims meeting specific criteria of concern are flagged and are examined during the on-site audit.

Discrepancies or issues are addressed during the on-site audit. Examples of discrepancies or issues include:

• Missing prescriptions
• Large number of no-substitution prescriptions
• Excessive quantity of drugs
• Unlikely drug combination therapy

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