Executive Summary

A national multiemployer health plan, operating in a dynamic healthcare environment, approached Withum with concerns regarding the accuracy, timeliness, and completeness of rebates from their Pharmacy Benefit Manager (PBM). Faced with uncertainty about rebate compliance, a complex rebate agreement, and resource constraints, the client sought Withum’s expertise. To address these challenges, Withum worked with the client to design and implement a strategic approach, including a comprehensive rebate audit, data analysis, and strategic negotiation.

The Client

A National Multiemployer Health Plan.

The Challenge

The client had been facing several challenges with their rebate agreements. Firstly, they had lingering doubts about their PBM’s adherence to rebate agreements, which raised questions about the financial benefits they were rightfully entitled to. Secondly, the intricacies within their rebate agreement made it difficult to ensure all rebates due were accounted for and received. Thirdly, limited internal audit resources and expertise within the client’s organization hindered their ability to conduct a comprehensive rebate audit and engage in effective negotiations with the PBM. These issues have made it difficult for the client to manage their finances effectively and maximize the potential benefits of their
rebate agreements.

The Approach And Solution

Our team convened with the plan sponsor and key stakeholders, dedicating time to comprehend the intricacies of the issue. We delved into the rebate contract with the PBM, meticulously scrutinizing the reimbursement methodology to ascertain the best evaluation approach. Leveraging our extensive experience and history with the PBM, we worked with the plan sponsor to design and implement the following strategic approach:

  • Comprehensive Rebate Audit: Withum launched a meticulous audit of the client’s rebate processes, designed to uncover unclaimed rebates.
  • Data Analysis and Validation: Employing advanced data analysis techniques, we validated the accuracy of rebate calculations, ensuring that every entitlement was accurately accounted for.
  • Negotiation and Settlement: Armed with a comprehensive understanding of the rebate agreement and backed by data-driven insights, we engaged in strategic negotiations with the PBM to secure previously unclaimed rebates.

The Results, ROI

  • Discovery of Unclaimed Rebates: Through a thorough audit and strategic negotiation, we successfully identified $1.7 million in unclaimed rebates, rightfully belonging to the client.
  • Successful Settlement: Negotiation and resolution efforts culminated in the client finally receiving their long-overdue rebates.
  • Enhanced Financial Health: This substantial recovery bolstered the client’s financial health.

Withum designed and implemented a strategic approach, including a comprehensive rebate audit, data analysis, and strategic negotiation. This resulted in the discovery of $1.7 million in unclaimed rebates rightfully belonging to the client. Through successful negotiation and resolution, the client not only received their long-overdue rebates, but also experienced a significant enhancement in their financial health. The client’s return on investment of 17:1 underscores the substantial financial benefits it realized through our services.

Contact Us

For more information or to discuss your business needs, contact Withum’s Self-Insured Health Plan Advisory Services Team.