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.
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.
Brian Bullock, Founder and CEO at The Burchfield Group, presented his perspectives on prescription drug innovation at the Minnesota Health Action Group’s 7th Annual Leadership Summit, Moving Forward in Uncertain Times, on February 21.
In January CMS announced it proposed 2015 policy and technical changes for Medicare Advantage (MA) and Medicare Advantage Prescription Drug (MAPD) programs. Plan sponsors have until March 7 to provide comments and feedback about the changes. Proposed changes apply to:
It’s easier to prioritize your efforts and meet CMS requirements when you understand the seven Medicare Part D standards and how they are weighted. Keep in mind the following as you prepare for the next data validation cycle.
In some cases, one document can do the work of validating several standards, saving you time and effort. For example, the guidance around validating Standards 4-7 shares common language about how to meet the requirements:
Even though SNP has the fewest data elements, it seems to generate the most questions. After multiple changes since 2011, the specifications are starting to align.
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.
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