It didn't take long for the "one bad apple" to rear its ugly head. A small union trust, about 1,000 members, had come to us with this problem. Their PBM budget was dangerously and non understandably out of control. And the culprit was nowhere in sight. As Cazma dug into the project and began our audit of the finances and budget, it soon became clear one culprit was a wayward prescription claim that had gone unnoticed. At this point, it was costing the small group about $21,000 a year. The solution was an easy one. Working with the physicians group, an equally effective but far less costly formulary alternative was recommended that reduced the overage several thousands of dollars a year.
Fraud and abuse are often buried far beneath the surface. Cazma has worked long and hard with many insurers to develop and implement strategies for reporting and processing that help to expose and gain better control over fraud, waste and abuse within pharmacy networks. In one such case, Cazma identified a single pharmacy that, over quite a number of clients and quite a number of years, was responsible for several hundreds of thousands of dollars in fraudulent prescription activity. The fraud was exposed and much of the money recovered.
Medicare can be a challenging benefit to add to and provide as a complement to a group plan. The fact is, Cazma has worked with employer groups of all sizes and age groupings to provide such a benefit to these members. Often, we have simply worked with these groups to convert the employer groups from Retiree Drug Subsidy (RDS) Programs to an Employee Group Waiver Programs (EGWP). Without going into great detail, the solution is fast, easy and very economical.
We have worked with numerous clients to develop strategies and easy-to-implement programs for gaining greater control over pharmacy costs. We have now fine-tuned these many measures and can offer them to clients of all sizes, with any number of members and any number of annual prescriptions. In perhaps our largest savings and one of our most memorable cases, Cazma audited and analyzed, then acted quickly and efficiently, and was able to identify and isolate an overall cost saving strategy tailored to a rather small group and the individual needs of its members which resulted in over $1 million in savings.
This is one of our easiest to tell and most repeatable case histories. We have worked with numerous large insurer clients over the years. One of their most often requested services is the attainment of accreditation for their pharmacy businesses. Long story short: We can do this all day, every day. And we have done it for enumerable clients. Accreditation bodies we work with, as a matter of ongoing practice, are Medicare, Medicaid, the National Committee of Quality Assurance (NCQA) and URAC.