Pharmacy Consultant

OIG: CMS Should Do More to Reduce Medicare Fraud

The U.S. Department of Health and Human Services’ Office of Inspector General has called on the Centers for Medicare and Medicaid Services to take steps that officials believe would reduce fraud among Medicare Advantage and Medicare Part D plans.

In its 2019 report, “Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: Top Unimplemented Recommendations” the OIG outlined its top recommendations to reduce fraud, abuse, and waste amount HHS programs, including Medicare.

This blog focuses on the recommendations for Part D and Advantage (also known as Part C) for this year. 

OIG Unimplemented Recommendations 

– CMS should tighten its oversight for Part D payments for compounded topical drugs, which are often at risk for fraud, waste and abuse. The OIG report found that spending on compounded drugs increased by nearly 180% between 2010 and 2016. For its part, CMS has released a reminder memo of its policies for compounded topical drugs, but OIG officials believe more steps should be taken. 

– CMS should gather stronger, more consistent data from plan sponsors that includes information on the potential for fraud and abuse. By doing so, CMS oversight will improve to better detect and prevent fraud and other problems, the OIG says. Plans are not required to report potential fraud by pharmacies and providers to CMS – but they can by their own admission. Not as many do as the OIG would like, so it wants CMS to do a better job at data collecting. For its part, CMS has said it will start requiring plan sponsors to report their own data as well. 

– Medicare Advantage plans should be required by CMS to include ordering and referring provider identifiers in their encounter data. Encounter data is information submitted by health care providers, such as doctors and hospitals that documents both the clinical conditions they diagnose as well as the services and items delivered to beneficiaries to treat these conditions. Ordering and referring provider identifiers is not always required in encounter data and was often overlooked, the OIG says. Officials wants CMS to require Medicare Advantage plans to include ordering and referring provider identifiers from here on out.

Summary

With these recommendations, health plans should anticipate stricter regulations and guidance requiring reporting of potential fraud by network providers and updates to encounter reporting requirements. 

We Can Help

Tier 1 Pharmacy Consultants helps health plans navigate the often murky and confusing waters of CMS changes, regulations, and oversight. The rules change often, and it’s difficult for health plans to keep up, much less stay compliant. Our team can help. 

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.

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

Drug manufacturer rebate audit: Are you owed money?

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 

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.

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

The Biggest Takeaways from CMS’s Annual Spring Conference

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 

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.

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

What Are Your Health Plan’s New Year’s Resolutions?

Studies for years have shown that more than half of Americans make financial resolutions in the New Year. (Not surprisingly, the other half vow to lose weight.)

New Year’s Resolutions often include business goals. Building efficiency, saving money and increasing value should be at the top of every company’s list for 2019 – including health plans that offer prescription drug benefits.

That’s why it’s smart for busy health plans to team up with an expert who can help them reach their goals.

The team at Tier 1 Pharmacy Consulting offers benefit consulting services for health plans of all sizes to increase their capabilities, cut costs and improve the services they provide for members. We are an authority in Medicare governance and compliance so we can help plans that are already stretched thin ensure they are meeting regulations and avoid Centers for Medicare and Medicaid Services (CMS) audits and other problems that could otherwise arise.

For example, Medicare Advantage enrollees will have from now until March 31 to choose the health plan that is right for them, according to the CMS. That period had previously ended more than a month earlier, on Feb. 14. CMS also has reversed its rule prohibiting formulary design that would expand prescription drug choices for Part D health plans and their members.

Both of these are good things, but are you ready? There is a lot to do first; most health plans don’t have the time, resources or experts on staff that can ensure accuracy.

We can help.

Even though we opened our doors just this year, our founder is a clinical pharmacist with more than a decade of pharmacy benefit management experience. We collaborate and advise our clients so the pharmacy benefits they provide are stronger, always compliant and more cost-effective than ever before.

If you’re new to us, here’s a bigger overview of what Tier 1 can do for your health plan. Click on each link for more information. Many health plans need at least one – if not all – of these series.

We want to help you reach your 2019 health plan resolutions. Contact us today.

Happy New Year!

 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.

The truth is, 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.

Take a look at what we can do for you.

We are here to help. Let’s talk about how we can be there for your health plan. Want to learn more? Email us at info@tieronepc.com.

Think it’s Too Early for 2020 CMS Star Ratings? Think Again

The Centers for Medicare and Medicaid Services released its 2019 Star Ratings last month – which already has some health plans thinking about 2020.

If it seems far off, it’s really not. That’s because it takes time to ensure your health plan is doing everything it can to ensure a four or five star rating. It’s a challenging task, but it’s feasible.

Star Ratings are put out by CMS to give Medicare and Medicaid beneficiaries some insight into the quality of the health plan before they sign up.

Among other things, Star Ratings:

– 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.

– Focus on aspects of high-quality care within the control of the plan.

– Provide a complete, accurate, reliable, and valid picture of a health plan. Star Ratings also are used for compliance and monitoring.

Star Ratings are displayed on the on Medicare Plan Finder (MPF) so beneficiaries may consider both quality and cost in enrollment decisions. The Affordable Care Act established CMS’s Star Ratings as the basis of Quality Bonus Payments to MA plans. Beneficiaries can join a five star plan at any time through a special enrollment period.

How can you work to receive a higher rating in 2020? Let the team at Tier 1 Pharmacy Consulting help. We are experts in Medicare compliance.

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 2020 that will help your health plan improve its performance and achieve 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 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 

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.