Discover how to manage your next RFP with confidence to secure better PBM rates, service and innovation programs. Watch this short, on-demand PBM RFP webinar.
Watch this short, on-demand audit webinar to learn how to protect yourself from unexpected liability and why it's important to create a PBM audit strategy.
A smooth and seamless transition is no guarantee when you offer a new prescription drug benefit, change your existing benefits or move from one PBM vendor to another. Much can go awry. The most common repercussions include eligibility issues: member coverage is termed; claims are denied; copays are miscalculated. A pre-implementation audit can help protect your investment.
Remember last year when CMS issued last minute guidance that required plans to achieve 100 percent accuracy for Part C and Part D grievance sections? That small change made a big impact on scores (and not in a good way). Many plans suffered because of the new guidance. Standard 3 is all about data submission. Here are three easy ways to work toward 100 percent accuracy on all your reporting sections.
Have you ever had a data validation auditor penalize you for not having the proper documentation, even when you felt like you met the requirement? Knowing what kind of documentation you need to satisfy a CMS requirement makes all the difference. To protect your audit score—and save time and effort—focus on when CMS specifically requests a policy or procedure.
Standard 2 is the meat and potatoes reporting section. It identifies the reporting specific criteria (RSC) for each section. Understanding the specifications and how to meet them is critical. A mistake in Standard 2 could have a cascading effect that impacts your score.
If you want to score 100 percent for Standard 1, pay careful attention to your source documentation. As a first step, make sure to provide your data validation reviewer with documentation that is current and relevant to the reporting time period. For example, if you need to resubmit data, supply only the resubmitted data to your auditor, not the data that was submitted initially.
The data validation standards manual is the ruling document of the reporting specifications. An understanding of this manual will not only save you time in preparation, but it can mitigate your risks by helping you focus your efforts on areas that will have the largest impact on your score. Below is a brief overview of the standards and the breakdown of the audit scoring.
It’s open enrollment season. Time to make sure your Summary of Benefits and Coverage (SBC) is current and compliant. Here’s what’s new and what stays the same for 2014, plus a quick review of the impact to your pharmacy benefit:
For the 2013 Data Validation Audit Cycle, CMS introduced a new scoring requirement for the Part C and Part D Grievances reporting sections. Under the new requirement, plans must achieve 100 percent accuracy for these sections. They are no longer allowed a 10 percent variance in scoring. Few plans achieved perfect scores in the Grievances categories.
Laws can be applied differently. The spirit of the law is open to interpretation while the letter of the law requires clarity and precision. When you’re negotiating with your PBM for prescription drug services, it’s best to stick to the letter of the law: clear, defensible language and explicit definitions.
Prescription drug fraud, waste and abuse can occur among physicians, pharmacies and members. In all instances, it is detrimental. Identifying, researching and curtailing FWA improves the overall financial health of a plan and its entire membership.
© 2013 THE BURCHFIELD GROUP