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Are you getting the service, savings and performance you expect from your PBM?

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Discover how to manage your next RFP with confidence to secure better PBM rates, service and innovation programs. Watch this short PBM RFP video.

Don't let PBM mistakes put you at risk!

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Watch this short video to learn how to protect yourself from unexpected liability and why it's important to create a PBM audit strategy. 

Are you completely prepared to migrate your prescription drug benefits to a new claims platform?

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PBMs process millions of claims, not just yours. One human error can impact your bottom line, cause member disruption and cost you hours of administrative time. Learn what's at stake and how to best prepare for migrating your pharmacy benefits in this informative, on-demand webinar

Health Plan Insurer Blog

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Receive full value from your PBM rebates

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Rebate reviews and audits regularly surface PBM mistakes and contractual underperformance. Small miscalculations can easily impact your rebates and not in a good way. An independent rebate audit can make sure your plan receives what the PBM promised and that all rebates are passed back to you accurately.

Don't let CMS timeliness standards hurt your data validation score

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Burchfield's Guide to CMS timeliness standards

CMS has plenty of timeliness standards and keeping them all straight can be confusing. Use our handy guide to help stay on top of the days or hours needed to complete a decision or payment. CMS measures timeliness down to the minute, so keep vigilant records and remember to factor in time zone changes.


Complex 2014 Determinations reporting section challenges plans

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Even though Medicare data validation is in its fifth year of audit, the validation standards remain complex and continue to evolve. The Coverage Determinations and Redeterminations reporting section, formally known as Coverage Determinations and Exceptions, went through many changes between 2013 and 2014. Some of these changes added additional reporting sections and others consolidated some of the elements.

Poor scores posted for 2013 data validation SNP reporting

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Special needs plan (SNP) care management reporting is one of the most difficult data validation standards. The average SNP score in 2013 was only 96.4, the worst scoring section by a wide margin. (Part C Grievances was next at 98.)

Align data validation stakeholders to avoid last minute mistakes

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Management and oversight of data validation varies between health plans. Different plans may use an audit department, a compliance unit or a Medicare oversight department. However your plan is structured, having a centralized business unit in charge of data validation reporting can ensure clear and effective communication to all stakeholders. Consider the following ideas to help make your 2015 review a success.

Bad data validation scores reduce your star rating and bottom line

Data validation auditBad data validation findings can chip away at your star rating. The 2015 Medicare Advantage call letter highlighted four themes: bid review, decreasing costs, promoting creative benefit designs and improving beneficiary protections. Let’s look at one theme, beneficiary protections, to see how a bad data validation score could impact your plan’s star rating.

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Complex CMS changes may cut into your data validation score

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This is Part 2 of our 2014 data validation changes review. If you missed Part 1 you can view it HERE. In Part 1 we dealt with the data element changes for Part C. Part 2 will focus on Part D changes from the February 2014 Technical Specifications. Incorporating these changes is vital for plans to maximize their data validation scores.

Data validation data element changes and what to expect in 2015 audit

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The 2014 data validation audit has come to a close and I hope it was successful for you!

OIG reveals prescriptions for hospice enrollees paid in duplicate

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The Office of Inspector General (OIG) found that more than $33 million in prescription drug claims for hospice enrollees were paid twice in calendar year 2009: once under Medicare Part A and again under Part D. In response to the findings, Centers for Medicare and Medicaid Services (CMS) issued final 2014 guidance aimed at mitigating duplicate payments. The most significant change for sponsors is that, beginning May 1, plans should place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who elect hospice care.

Are your PBM pricing discounts seriously underperforming?

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Pricing guarantees are tricky. Even with a traditional arrangement (locked-in brand discounts and dispensing fees) you still have to account for generic pricing and aggregated guarantees often can’t be calculated until the end of the year. Measuring generic effective rates in the middle of a pricing term is difficult, too, and your PBM may argue that any sign of underperformance is not a cause for concern because the term is incomplete.

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