Detect hidden spread between ingredient cost reimbursed to pharmacy vs. amount billed to plan, quantify total spread revenue, and identify recoverable overcharges
Your PBM says they reimburse pharmacies "at cost." But when you audit the claims, you find they reimbursed the pharmacy $42 for a generic—and billed you $87. That $45 difference? It's called spread. Your PBM pocketed it. Multiply that across 500,000 Rx claims and you've funded their Vegas trip.
Our PBM Spread Pricing Detection Engine benchmarks every claim against NADAC + MAC pricing, identifies outlier reimbursements, flags spread revenue opportunities, and generates audit reports with recoverable overcharges itemized by NDC and pharmacy.
Spread Detection Algorithm// Real-time claim audit FOR each claim IN pharmacy_claims: plan_cost = claim.ingredient_cost + claim.dispensing_fee // Benchmark ingredient cost nadac_price = GET_nadac(claim.ndc, claim.fill_date) mac_price = GET_mac(claim.ndc, state, claim.fill_date) benchmark = MIN(nadac_price, mac_price) // Calculate spread spread = plan_cost - (benchmark + reasonable_dispensing_fee) IF spread > $5 OR spread_percent > 15%: // High spread detected FLAG claim for audit recovery_opportunity = spread × claim.quantity CATEGORIZE spread: IF spread > $50: "Extreme outlier — likely error or fraud" IF spread $10-$50: "Significant spread — review contract" IF spread $5-$10: "Moderate spread — track trend" // Aggregate by pharmacy pharmacy_total_spread = SUM(spread BY pharmacy_id) IF pharmacy_total_spread > $50K: FLAG "High-spread pharmacy — investigate relationship with PBM" // Generate recovery report total_spread = SUM(all flagged claims) potential_recovery = total_spread × recovery_probability where recovery_probability = 60-80% (contract dependent) OUTPUT: - Total spread PMPM - Top 20 NDCs by spread revenue - High-spread pharmacies - Recoverable amount by month
Benchmark every claim against NADAC + MAC. Detect spread pricing in real-time. Generate audit reports with itemized recovery targets. Stop funding PBM profit margins.
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