OIG conducts inspection of PBM program integrity activities

The OIG conducted an inspection to determine the program integrity activities pharmacy benefit managers (PBM) use to detect fraud, waste, and abuse of Medicaid-funded prescriptions.

The two PBMs selected by OIG rely on three program integrity activities to detect FWA in overbilling, unauthorized refills, and unauthorized drug substitutions in Medicaid-funded prescriptions. The three program integrity activities are: a.) Edit Checks of Submitted Prescription Claims, b.) Daily Prepayment Review of Covered Prescription Claims, and c.) Audit of Paid Prescription Claims.

You can read the complete inspection report at https://tinyurl.com/OIGProgramIntegrity