Automated PBM contract clause extraction, fiduciary scoring, and continuous monitoring of contractual guarantee fulfillment against actual performance metrics.
NLP-powered parsing of PBM, TPA, and carrier contracts. Extracts pricing guarantees, rebate terms, audit rights, MAC definitions, and fiduciary obligations into structured fields.
Every clause rated for ERISA compliance risk. Red-flag provisions like discretionary AWP benchmarks, undisclosed rebate retention, or limited audit windows surface immediately.
Claims data continuously tested against contractual obligations. Spread pricing exceeding agreed caps, rebate pass-through failures, or MAC overages flagged within 24 hours of occurrence.
Compare your contract terms against peer benchmarks and industry standards. Identify weak audit rights, excessive discretionary pricing, or missing fiduciary protections before renewal.
"PBM may use AWP as published by a nationally recognized source" gives PBM power to pick highest AWP. Require specific source (First Databank, Medi-Span) with quarterly snapshot dates.
"Annual audit, 30-day notice, limited to financial records" prevents continuous monitoring. Demand unlimited audit rights covering MAC lists, rebate calculations, and spread pricing methodologies.
"PBM shall share manufacturer rebates subject to GPO agreements" hides retained rebates. Require 100% pass-through disclosure with manufacturer names, rebate amounts, and retention justifications.
Comprehensive governance framework for board members and plan fiduciaries — defense-ready documentation and continuous oversight infrastructure.
Timestamped audit trail with complete chain of custody
EBITDA quantification and board-ready financial models
Cross-system verification and data integrity validation
Automated clause extraction and guarantee enforcement
Monte Carlo simulations and credibility-weighted forecasts
Transaction-level anomaly detection and forensic alerts
ERISA compliance monitoring and DOL audit readiness
AI-powered trend forecasting and intervention modeling