Pharmacy Claims Audits

Express Scripts Canada's Audit Programs* verify that claims are paid for authorized prescriptions only, and that pharmacies charge prices within their contractual limits. These audits help eliminate waste and manage costs, with proven savings to clients. Express Scripts Canada participates in a number of industry audit initiatives, including the Canadian Health Care Anti-Fraud Association (CHCAA).

The Express Scripts Canada Pharmacy's Business Integrity Department provides quality, cost-effective services to Express Scripts Canada’s clients and to their members. The audit programs ensure the integrity and accuracy of the data in the claims-adjudication system. Customers are informed annually of the results of the audit programs.

Together with customers, Express Scripts Canada works to resolve situations in a timely manner that may involve fraud or abuse. The Express Scripts Canada pharmacy audit team includes about 20 professionals, including licensed pharmacists, pharmacy technicians, and other individuals with experience verifying the accuracy of pharmacy claims.

Express Scripts Canada is a member of the Canadian Health Care Anti-Fraud Association (CHCAA) and takes part in a number of industry-wide audit initiatives. To facilitate these projects, Express Scripts Canada uses multiple audit programs, including:

• Written Desk Audits: Targeted documentation is requested from the pharmacy and reviewed with in-house pharmacy dispensing information.
• On-Site Audits: The Express Scripts Canada auditor visits the pharmacy (if deemed appropriate) to perform a comprehensive review of claim and quality-assurance documentation and procedures. A mutually acceptable date and time is arranged. Sites are chosen in a variety of ways, including targeted, random, and outside recommendations. The objective is to audit as many different pharmacies as possible over time.
• Next Day, On-Line Desk Audits: On-line claims from the previous day are automatically flagged using predetermined criteria and subjected to audit procedures. Express Scripts Canada may request a copy of prescriptions to be faxed for verification.
• Physician Verifications: The prescribing physician is asked to verify information from pharmacies, members and specific claims.
• Member Verifications: Prescription receipts and specific claim information is substantiated through member contacts.