Validity of Electronic Prescription Claims Records: A Comparison of Commercial Insurance Claims with Pharmacy Provider Derived Records

Abstract

Objectives: To determine if and to what extent records obtained from PBM pharmacy claims differ from source documents obtained directly from pharmacy providers. This study also sought to explore possible associations between patient, pharmacy benefits, and pharmacy provider characteristics and the likelihood a patient would have missing prescription claims. Methods: This study used a cross-sectional design which included a sample of 1,484 patients residing in a single state with a common pharmacy benefit. Profiles describing all prescriptions filled in a pharmacy between January 1, 2002 through June 30, 2002 of these patients were requested directly from their pharmacy providers. Logistic regression was used to explore the factors associated with a person receiving a prescription that did not appear on the PBM claims. Results: Of the 1,484 eligible recipients sampled, profiles were obtained for 323 (22%) persons and there were analyzable profiles for 315 (21%) persons. There were a total of 2,977 prescriptions filled for the 315 subjects. Of those 2,977 prescriptions, 207 (7.0%) were missing from the claims files indicating that 93% were captured. Only prescription volume consistently influenced the likelihood a patient would have a missing prescription from the PBM claims (OR =1.08; 95%CI:1.05-1.12). Conclusion: Claims obtained from pharmacy benefit companies capture approximately 93% of prescription records when verified with records obtained from pharmacy providers. The rate of missing records from PBM claims does not appear to be meaningfully influenced by most finance based pharmacy benefit design features. However, certain classes of drugs such as iron products, digoxins, diuretics, sulfonylureas, and antigout may have incomplete claims records compared to other classes of drugs. Higher prescription utilizers are more likely to have prescription records filled that are not captured by PBMs. These conclusions should be interpreted in light of the modest usable response rate from pharmacy providers of 22% and the unknown generalizability of these patients utilizing one particular PBM from 2002 in the state of Georgia.