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.
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.
The 2014 data validation audit has come to a close and I hope it was successful for you!
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.
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.
© 2014 THE BURCHFIELD GROUP