Case Study: Retail Pharmacy achieves $8M+ in recoveries and improved regulatory compliance with SCIO Health Analytics

Retail Pharmacy - Customer Case Study

Retail Pharmacy, a top PBM, needed onsite audits to assess pharmacy compliance with state and federal rules (including the Hernandez Settlement and CMS Medicare Rights Notice) but lacked the internal resources and specialized auditors to review pharmacy claims. SCIO Health Analytics was engaged to provide onsite audit services along with prescription analytics, predictive modeling, auditor expertise, and efficient audit workflow software.

SCIO Health Analytics deployed auditors, completed audits and reporting with an average pharmacy closure time of 75 days, and established an ongoing, geographically efficient onsite audit program. The engagement recovered over $8,000,000 across 1,700 pharmacies (about $4,700 per pharmacy) and uncovered key discrepancies such as undocumented substitutions, unauthorized refills, missing prescriber signatures/valid prescriptions, missing prescriptions, and non‑compliance with HSA and CMS Medicare Rights Notice.