Centers for Medicare and Medicaid Services Archives • Tier 1 Pharmacy Consulting

2020 Readiness Checklist for Medicare Advantage Organizations & Prescription Drug Plans

November 27, 2019

Last month, HPMS released a memo outlining its 2020 Readiness Checklist for Medicare Advantage Organizations and prescription drug plans.

The Centers for Medicare and Medicaid Services recommends all Medicare Advantage and prescription drug plans review the checklist – and take the appropriate action to meet the requirements next year. Health plans should closely review the entire checklist to ensure compliance. Remember, the checklist isn’t a compilation of suggestions from the government. Instead, it’s a summary of the most critical requirements.

Here’s a few examples of what’s in the readiness checklist for 2020:

Medicare Plan Finder Data. Part D Sponsors must provide access to the Health Plan Management System Part D Pricing File Submission Module.

Prescription Drug Event Requirements. Part D Sponsors must submit the data CMS needs to carry out payment provisions through the Prescription Drug Front-End System and processed by the Drug Data Processing System.

Coverage Gap Discount Program. The agency is asking Part D Sponsors to understand their responsibilities to participate in the CGDP, and provides information about the CGDP portal, onboarding training and more.

Precluded Providers and Prescribers. CMS has bigger expectations for 2020 when it comes to managing precluded providers and prescribers. Moving forward, MAOs/Part D Sponsors must, when when a prescriber is on the Preclusion List, deny payments for reject a pharmacy claim, deny a beneficiary request for reimbursement, or deny a health care service.

What Can Your Health Plan Do Next Year?

Tier 1 Pharmacy Consuting can make a readiness assessment for your health plan or prescription drug plan to ensure you are prepared and identify potential problems before they begin.

Get Started

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2021 that will help your health plan improve its performance and achieve your goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be complicated or overwhelming. It’s important that you earn the highest rating possible.

A four or five star rating is within your reach for 2021. We can help you get there.

About Tier 1

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS Star Ratings Sees Improvements This Year

November 15, 2019November 15, 2019

Last month, the Centers for Medicare and Medicaid Services its released its Star Ratings findings for 2020 with some great news: More plans rated four stars or higher this year compared to the year before.

To get more specific, more than 50 percent of plans rated four and above, up from 45 percent. In addition, the enrollment weighted average increased from 4.06 last year to 4.16 this year. Twenty plans earned five stars, yet another sign of continued improvements.

Why Does it Matter?

Most Medicare Part D and Medicare Advantage plans understand the importance of Star Ratings. The ratings are put out annually by the Centers for Medicare and Medicaid Services to give beneficiaries a look at the quality of the health plan before they sign up. Star Ratings focus on aspects of high-quality care within the control of the plan. They provide a complete, accurate, reliable, and valid picture of a program. Star Ratings also are used for compliance and monitoring, and measure aspects of a plan that are relevant and important to beneficiaries. CMS looks to NCQA, PQA and others for measure concept development, endorsement, and specifications.

Star Ratings are displayed on the Medicare Plan Finder – which recently got a huge facelift – so seniors may consider both quality and cost in their enrollment decisions. In other words, Star Ratings are very important.

Other Key Findings

CMS also found that:

– More than 80 percent of beneficiaries are now enrolled in plans with 4 or more stars, up from 75 percent last year.

– This year, 141 plans earned higher 2020 ratings than they did in 2019.

– Only 57 health plans saw their overall ratings drop year-over-year.

– This year, 56 plans earned a4th star.

– Only 21 plans lost their 4th star this year.

– Approximately 52 percent of contracts for Medicare Advantage plans offering Part D coverage earned 4 stars or higher, compared to about 45% in 2019.

– Of 401 total plans for 2020, 210 are at 4 stars or higher, compared to 172 in 2019 when there were fewer plans – 376 to be exact.

– The comparison between 2020 and 2019 shows 55 contracts rated 3 stars for 2020 as opposed to 66 in 2019.

– The average star rating for a stand-alone prescription drug plan has improved from 3.34 in 2019 to 3.50 in 2020.

– There’s about 1,200 more Medicare Advantage plans operating in 2020 than in 2018, according to the Centers for Medicare and Medicaid Services.

What Can Your Health Plan Do Next Year?

If you didn’t achieve four stars this year, you have time to improve and influence your 2021 ratings with the right strategy, data, and attention to detail. It’s important that you review your current performance figures and use the right resources moving forward.

If you earned four stars this year – congratulations! However, now is not the time to sit back and relax. Star Ratings is a competitive process, and the health plans who get top billing have already started taking steps to ensure the same if not better performance next year.

Get Started

A four or five star rating is within your reach for 2021. We can help you get there.

About Tier 1

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS Announces 2018 Parts C and D Audit Report

October 2, 2019October 3, 2019

The Centers for Medicare and Medicaid Services (CMS) last month released the agency’s 2018 Medicare Part C and Part D Program Audit Report. Such reports can be challenging to navigate through, but it’s important that health plans understand them in the event they experience an audit.

Background

The Medicare Parts C and D Oversight and Enforcement Group (MOEG), a division of CMS, releases the report every year. It includes data from recent audits. The idea is to explain CMS initiatives and boost transparency of the entire auditing process. Program audits are conducted by MOEG to ensure Medicare Advantage and prescription drug plans are offering the right access to health care services and medications to enrolled seniors.

As CMS writes: “Regular and consistent auditing of these organizations…provides measurable benefits by:

• Ensuring enrollees have adequate access to health care services and medications; • Verifying sponsors’ adherence to selected aspects of their contract with CMS;

• Providing a forum to share audit results and trends; and

• Soliciting feedback from the sponsor community and external stakeholders on potential audit improvements.”

2018 Highlights

Changes to audit processes based on sponsor feedback. Among other things, CMS expanded technological capabilities and reduced the scope of data collection to make submissions more streamlined. It also extended the fieldwork phase from two weeks to three weeks, and made the audit validation and close-out process better.

Audit results. CMS reports lower overall audit scores between last year and the year before, from 1.10 in 2017 to 1.03 in 2018. Scores were lower in Part D Formulary and Benefit Administration (FA) and Part C Organization Determinations, Appeals and Grievances (ODAG). Average FA scores, though, showed improvement with a reduction of 62% in 2018.

Audit Enforcement. CMS imposed $396,736 in 10 CMPs. There were three intermediate sanctions against sponsors for non-compliance, but fewer CMPs imposed for 2018.

To view the full report, go here.

Medicare plans and pharmacy teams are increasingly subject to closer CMS monitoring and review, so an audit is more likely now than ever before. Typically, CMS audits plans once per audit cycle, which runs between three to five years. It’s important to be ready for an audit – especially if your health plan has performance issues. Tier 1 Pharmacy Consulting provides support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to ensure compliance and get you through the process.

Get Started

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be scary. It’s necessary to get you the best rating possible. We will make sure your vendors are on board, too, supporting your efforts and all of the needs of the Star Ratings plan.

A four or five star rating is within your reach for 2020. We can help you get there.

About Tier 1

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected

CMS unveils new-and-improved Medicare Plan Finder

September 15, 2019September 16, 2019

Seniors will have an easier time shopping for health plans and drug coverage thanks to a major overhaul of one of the government’s key online services.

The Centers for Medicare & Medicaid Services last month unveiled a new-and-improved Medicare Plan Finder on the Medicare.gov website. The move is part of the government agency’s eMedicare initiative to create a modern, personalized, and seamless customer experience for Medicare recipients.

It’s the first time in a decade that CMS has made changes to the system, and the new plan finder and related technology facelift comes just ahead of annual open enrollment when seniors begin in October to choose their plans for 2020.

A Needed Makeover

The plan finder upgrades include:

– A more simple login process to Medicare recipients’ online accounts.

– A fast drug list builder that reviews recipients’ prescriptions over the previous 12 months and suggests generic alternatives to name-brand drugs.

– More details on the different Medicare Advantage plans so seniors can easily compare benefits and choose the plan that is right for them.

– A guide for seniors to compare original Medicare, supplemental policies and Medicare Advantage plans, as well as up to three drug plans or three Medicare Advantage plans side-by-side.

Why Now?

In July, the Government Accountability Office (GAO) in a study determined that the Medicare Plan Finder was challenging for beneficiaries to navigate. It also provided incomplete information and information that was tough to find and even tougher to understand.

The Medicare Plan Finder was created to provide all of the health plans available in a person’s zip code, with crucial information about premiums and out-of-pocket costs, particularly for prescription drugs. Pricing is different for every health plan, so the tool aims to help consumers make informed decisions about what kind of health and pharmacy care plan they need – and how much they can afford. Plan Finder drug prices are updated regularly from October through August. Pricing for the current year is frozen in September in preparation for the new plan year’s display.

Under the changes, the new Plan Finder makes choosing a plan much easier and more user friendly. It’s also a welcome change for health plans, who have spent time and money trying to improve their own networks to offer people over age 65 private Medicare Advantage coverage, according to Forbes. Experts predict enrollment in private Advantage plans could rise as high as 70 percent between 2030 and 2040. If all goes as expected, the now easy-to-use Plan Finder could boost Medicare Advantage enrollment even further.

“The new Plan Finder walks users through the Medicare Advantage and Part D enrollment process from start to finish and allows people to view and compare many of the supplemental benefits that Medicare Advantage plans offer,” CMS said in a statement.

What Health Plans Need to Do

To keep the Plan Finder information current, Medicare requires health plans to submit files that update the costs of prescription drugs every two weeks. Many plans delegate this function to their PBM, but it’s important that health plans stay engaged in this process and ensure that there are effective processes to oversight these frequent submissions. Medicare wants to make sure enrollees are provided the most accurate information when making the decision on what prescription drug plan works best for them.

If a health plan fails to update its prescription drug pricing and other information, it could be suspended or removed from the Medicare Plan Finder. The plan won’t show up when consumers do a search using the tool, so they won’t even know your health plan exists. That means less money going into your health plan and an overall loss of revenue over time.

How We Can Help

The team at Tier 1 Pharmacy Consulting can be the liaison between the health plan and the pharmacy benefit manager to help oversee the steps needed to ensure CMS compliance, including regular updates to the Medicare Plan Finder. We can offer solutions on how to properly and effectively institute the appropriate process for oversight and ensure drug prices are, at all times, accurate and up-to-date all year. We are experts in Medicare. Avoid a Plan Finder suppression by partnering with us. We can help you stay compliant at all times, so you can focus on running your health plan.

About Tier 1

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS Seeks Comments on Proposed Audit Protocol Changes for 2020

August 27, 2019August 27, 2019

The Centers for Medicare and Medicaid Services (CMS) announced in a recent memo that officials are seeking comments to their proposed audit program protocol changes. This blog will outline some of the most important changes and a reminder of steps health plans can take if they receive a CMS audit notification.

Key Proposed Changes Through 2020

Formulary Administration “‘Website” section removal of the Audit Process and Data Request
Transition sample size from 15 to 30
Removal of the CPE Self-Assessment Questionnaire and the ODAG Supplemental Questionnaire
Removal of ‘Dismissals’ from the data integrity sampling
Removal of OD approved cases from the Clinical Decision Making section
Increased the Grievance sample size
Removal of ‘Enrollment Verification’ audit element for SNP MOC
Removal of the Medication Therapy Management audit area

For the full list and a closer look at all of the proposed changes to audit protocols, check out the memo here. CMS is accepting comments through Oct. 15.

Many of the changes would reduce the burden on health plans. Even so, health plans should review any and all changes. The chance of a plan getting a program audit has increased and continues to grow. CMS is now reaching out to nearly 100% of plans every four via plan audits. Audit notice letters are typically sent March through July.

Plans should take steps sooner rather than later to address the changes and anticipate an audit in the future. The best way to deal with a CMS audit is to be prepared.

We can help.

The team at Tier 1 Pharmacy Consulting provides support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses, create corrective action plans and more. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions and help you through the process from start to finish.

Tier 1 CEO Brent Hiley has been both the lead for CDAG (coverage determinations, appeals and grievances), the lead for FA (formulary administration) and even overall audit director, ensuring coordination of all elements related to data requests, deliverables, impact analysis and root cause summaries. He can provide onsite audit support for teams to ensure they are prepared for various questions that might be asked and coach them on how to approach certain aspects of the audit.

About Tier 1

CEO Brent Hiley is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Drop us a note at info@tieronepc.com. We’re here to guide your health plan every step of the way.

Drug manufacturer rebate audit: Are you owed money?

July 21, 2019July 29, 2019

There is one kind of audit a health plan actually wants: A drug manufacturer rebate audit.

What is a drug manufacturer rebate audit?

A drug manufacturer rebate audit is an in-depth look at a health plan’s rebate agreement previously put in place by drug manufacturers and a pharmacy benefit manager. The idea behind a rebate audit is to ensure that a health plan is recouping the most money possible through its drug benefit.

Why should health plans seek rebates from drug companies?

Brand-name prescription drugs are expensive, especially for medications that treat many serious, yet common medical conditions. Rebates are often the deciding factor when a health plan chooses to cover a drug and how much of the cost should be covered by a patient.

Medicare Part D members, for example, are likely to pay anywhere between $12.40 and $77.40 and higher for prescription drug coverage, according to Medicare.gov, and that doesn’t include the required copay when you get to the pharmacy counter, which runs anywhere from $5 for generic drugs and $25 to $40 for name brand prescription medications. There are many reasons a health insurer may choose to cover or not cover a name brand prescription drug, but manufacturer rebates are a big one.

How does a drug manufacturer rebate audit work?

A drug manufacturer rebate audit analyzes the rebate agreements that exist between a health plan and drug manufacturers – typically the top five to ten manufacturers that contract with the PBM. The top is selected based on dollar value of the rebates on the drugs, often the top 50% to 75% of all rebates invoiced.

Very few health plans conduct drug rebate audits. But as the possibility of more money to recoup grows, audits are likely to increase as well. Plans often are not receiving the level of rebates they are entitled to due to formulary exclusivity provisions in the contract. Or, competitor drugs on the formulary have limited PBM rebates. At the same time, incorrect goals and invoicing can result in wrong or limited rebate payments to the health plan.

A drug manufacturer rebate audit can identify all of those problems and more. Many audits are conducted annually; sooner if there have been recent changes to PBM payments or the plan. Most Medicare Advantage plans report directly and indirectly to the Centers for Medicare and Medicaid Services (CMS). CMS expects rebate oversight if it conducts its own audit.

How do health insurers choose an drug manufacturer rebate auditor?

An independent auditor must have lengthy experience in drug manufacturer rebate audits. The process is complicated at best. It’s also wise to have a consultant there to guide you through the process, which can take months. A team of experts assisting can help ensure you get the rebates the health plan is entitled to receive.

Tier 1 Pharmacy Consulting can help

The team at Tier 1 Pharmacy Consulting works closely with health plans on every single aspect of their prescription drug benefits. Health plans are always looking to do more — but sometimes the resources just are not there. Let Tier 1 assist you with opportunities that might be limited by time and resources – including the chance of recouping drug manufacturer rebates.

We want the same thing as our clients and their members: high quality prescription drug options at the lowest possible cost. We are sensitive to the need for lower prescription drug costs. At the same time, we believe it’s important to increase the value that the plan provides, and look for savings and rebates whenever possible.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

CMS to audit Medicare Advantage plans in response to overbilling

July 20, 2019July 20, 2019

The Centers for Medicare and Medicaid Services (CMS) is at the center of a controversy that could affect health plans across the country.

Last week, national news outlets – including National Public Radio – reported that CMS is proposing a series of new audits designed to take back $1 billion of the $30 billion the government says health insurers have overcharged Medicare in the last three years. CMS’ goal is to recoup some of that money by 2020. With the new year just five months away, the government could move full steam ahead with its plan – and health plans should be prepared.

Some background, as noted in the NPR story and others:

Some Medicare Advantage plans, the government says, have tried to boost their revenues by billing Medicare more than necessary. These plans have done so by stretching the truth on how much medical care their elderly patients need. Or, plans have charged Medicare for treating illnesses and conditions they can’t prove their members have truly been diagnosed with.

With 22 million seniors – that’s one in three men and women over the age of 65 – on Medicare, the problem is nothing new. In fact, CMS has known about inflated billing practices for several years; the agency has long considered auditing plans before to address billing dishonesty and mistakes but before had always backed off.

Meanwhile, the U.S. Department of Health and Human Services Inspector General’s Office has kicked off its own round of nationwide Medicare Advantage audits of health plans billing practices.

The scrutiny is growing.

The insurance industry, for its part, is highly critical, arguing CMS audits are unfair and have the potential to negatively impact seniors’ medical care.

“If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care,” Insurer Cigna Corp. wrote in a May financial filing.

If CMS proceeds with the audits, the penalties are unclear for health plans who are accused of overbilling Medicare.

It’s important to be ready at all times for an audit – especially if your health plan has faced CMS oversight in the past. Being prepared will help plans identify and respond to potential gaps and address them as quickly as possible. The normal audit process is extensive, so one can imagine this latest round of audits will be in-depth at best. Plans are going to need help – and that’s where Tier 1 Pharmacy Consulting can help.

We provide support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. Even for the kind of audits that are forthcoming.

With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to get you through the process and avoid fines if at all possible.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

New CMS Rules to Increase Transparency and Lower Drug Costs

June 29, 2019June 30, 2019

The Centers for Medicare and Medicaid Services (CMS) recently published a final rule intended to increase transparency and lower drug prices. This announcement has been in the works since CMS first posted their proposal in November 2018. Now that the final ruling has arrived, it’s important for health plans to understand what’s changed and how the rule may affect their business. Tier 1 is available to consult with health plans about these important updates. In the meantime, here’s a brief look at what this final rule means for health plans and the health care industry more generally.

What Does the Final Rule Mean for Your Health Plan?

If you’ve been following along with this blog, this topic will already be familiar to you—we’ve been keeping you posted about its various updates since the proposal was first announced. Published on May 23, the CMS’s final rule is formally entitled, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.” As the title suggests, the amendments within the final rule pertain to both Part C (Medicare Advantage program) and Part D (Prescription Drug Benefit program) regulations. The amendments aim to help health plans negotiate for lower drug prices and reduce out-of-pocket costs for enrollees of Part C and Part D programs. The CMS ruling achieves this aim by improving regulatory frameworks and facilitating the development of products that meet patient needs while also reducing their fees. Health plans only want the best for their members—and reducing patients’ out of pocket costs help minimize the expenditures of Part C and Part D programs.

What Does the Final Rule Say that Your Health Plan Needs to Know?

On the same day they published their final rule, CMS posted a helpful fact-sheet outlining significant changes that your health plan needs to consider moving forward. Key takeaways include:

Part D policy relating to six classes of drugs has now been codified.
Part D plans are now required to adopt one or more electronic Real Time Benefit Tools that have the capability to inform prescribers when lower-cost therapies are available under their drug benefit.
Policy is now being finalized that would allow Medicare Advantage plans to implement step therapy for Part B drugs as a recognized utilization management tool.
CMS will now require Part D plans to inform members of drug price increases and lower-cost therapeutic alternatives in their Explanation of Benefits.
A new prohibition against gag clauses in pharmacy contracts now restricts Part D sponsors from prohibiting or penalizing a pharmacy from disclosing a lower cash price to an enrollee.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

The Biggest Takeaways from CMS’s Annual Spring Conference

June 28, 2019

This spring, the Centers for Medicare and Medicaid Services (CMS) held an event that you and your health plan will want to know about. Each year, CMS’s annual Medicare Advantage & Prescription Drug Plan Conference provides important information to health plan provider staff, management, and executives regarding updates to existing Medicare policies, technology, and much more. This year proved to be no different—and we want to share with you some key updates that may impact you and your business now and into the future.

The one-day conference provided a number of important takeaways regarding All Payer Policies, Medicare Advantage Qualifying Payment Arrangement Incentives (MAQI), eMedicare, and more. Below, we outline two topics that we believe will have a significant impact on you and your health plan.

Medicare Advantage Value Based Insurance Design Update

In order to succeed in the health care space, health plans must shape their priorities based on the most up-to-date information available to them. CMS’s spring conference offered the opportunity to not just receive the latest news, but to peer into the future and prepare for what’s to come in the industry over next several years. Of particular interest was CMS’s overview of the future of its Value Based Insurance Design model. Starting in 2020, this model will begin incorporating significant innovations, from allowing health plans and other organizations to design targeted benefits for enrollees based on chronic condition or socioeconomic characteristics to providing meaningful rewards and incentive programs. In 2021, CMS will be testing the possibility of adding a Medicare hospice benefit to this program as well. CMS’s stated goal is to promote patient-centered care and increase access through innovative means. We are certainly excited about these what these future benefits might mean for our health plan clients.

Medicare-Medicaid Integration Policies

One of the great benefits of CMS’s annual conference is the clarity experts provide on some of the most complex policies and rules that health plans must abide by. A panel dedicated to explaining new integration related to Parts C and D Rules for Dual-Eligible Special Needs Plans (D-SNPs) provided several valuable takeaways. These Rules address both policy and technical changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly (PASE), Medicaid Fee-for-Service, and Medicaid Managed Care Programs for 2020 and 2021. This session highlighted important contexts for making updates to the regulations, specific regulation changes, and various operational considerations.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

Should my health plan outsource or handle CMS compliance in-house?

May 26, 2019May 27, 2019

Why You Should Outsource Your Health Plan Headaches

Benjamin Franklin once said nothing in this world is certain except death and taxes. In twenty-first century America, this quote could be updated with a refrain: Nothing is certain except death, taxes, and the labyrinthine nature of our healthcare system.

Right now, the United States is in a state of flux when it comes to health care compliance. As lawmakers move towards different ends of the spectrum when it comes to how health care should be managed in this country, and by whom, health plans are often left to muddle through endlessly complex and quickly-changing rules and regulations. Changes occur so quickly in the health care space that it can seem like the Centers for Medicare and Medicaid Services are throwing out new regulations by the day. How can health plans keep up with the pace while also focusing on their clients’ needs and meeting their bottom line?

The answer is simple: by partnering with Tier 1 Pharmacy Consulting, health plans free up hours in their workday and save their employees time and countless headaches. CMS audits, guidelines, regulations, and changes to all of the above can be confusing. Outsource the work to us and your health plans will never have to worry about important business decisions falling through the cracks – possibly costing thousands of dollars and years of scrutiny.

Pharmacy Benefits Don’t Have To Be Complicated

At Tier 1, our goal is simple: Offer our health plan customers strategic, cost-saving solutions that boost the plan’s overall value and help its members by proving high-quality care. The way we go above and beyond that goal is just as simple: We offer a full suite of services designed specifically to save health plans both time and money.

Is your health plan well-versed on CMS’s 2019 update to the agency’s audit program? Every year, the CMS conducts thousands of audits, from BID audits to Formulary Administration audits, Transition Monitoring Program analysis, Data Validation audits and more. For some health plans, it would take a year just to work through the 2019 update, let alone take measures to prepare for the audits that may come along at any time. Tier 1 helps hundreds of plans a year by taking the grunt-work out of audit preparation: by outsourcing audit woes to Tier 1, health plans not only save time and money, but also greatly reduce their chances of paying fines due to accidental oversight.

Audits are just one example of what Tier 1 can offer health plans to make their schedules lighter and more able to innovate in other ways. We also help health plans to get answers to compliance questions more efficiently by acting as a liaison between them and pharmacy benefit managers. If your health plan has ever had questions about something as deceptively simple as website management or as straightforwardly complex as finding a new pharmacy benefit manager altogether, let Tier 1 help: we have the expertise and the insight needed to help health plans and PBMs get on the same page fast.

Reach Out Now and See What’s Possible

What would your health plan do if they didn’t have to worry about the endless complexities of CMS rules and PBM issues? It’s time to start thinking big. Hire Tier 1 Pharmacy Consulting today and start to see what’s possible for the future of your health plan.

Get in touch.

About Tier 1