Health Insurance

CMS unveils new-and-improved Medicare Plan Finder

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 

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.

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.

CMS to audit Medicare Advantage plans in response to overbilling

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 

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.

CMS FAQ’s to Audit Program: What You Should Know

The Centers for Medicare and Medicaid Services receives hundreds, if not thousands, of emails from health plans with questions about changes and updates to the agency’s audit program. In many cases, CMS says, the same answers are sought. Because of that, the agency has published an outline of the questions organizations tend to ask most frequently.

A little background: CMS releases changes and updates to its Program Audit Process every year so health plans know what to expect in the event they are audited. Such probes include CMS program audits, PDE audits, one-third Financial audits, BID audits, Formulary Administration audits, Transition Monitoring Program Analysis, Coverage determination/redetermination Timeliness audits and Data Validation audits.

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. Even so, it’s important to be ready for an audit – especially if your health plan has performance issues.

Audit notifications for 2019 will be sent out starting this month. If you receive a notification, give us a call. 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 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 compliancy and get you through the process.

Back to the FAQ. Below,  we highlight a few things health plans are most concerned about. The entire CMS article can be found here: https://go.cms.gov/2J7kR4b

Universe Submissions

CMS has tips for preparing universe submissions in the hopes of making the process a little smoother on both sides. For example, the agency suggests that plans direct any universe questions that arise to the area Team Lead before submission. Plans also should answer “not applicpable” answers as “NA” not “N/A” as seen on many question and answer forms.

Compliance Program Effectiveness (CPE)

CMS has started collecting Call Logs, which help identify misclassification of coverage requests during the Compliance Program Effectiveness portion of an audit. The agency plans to use other ways to look at requests that are filed incorrectly, such as reviewing how well a plan oversees the call-routing process.

Health plans should expect to be evaluated. However,  collection of call log data is suspended for 2019.  Health plans should still add call log auditing and monitoring activities to their to-do lists and have a documented oversight process in place.

Part D Formulary and Benefit Administration (FA)

CMS says the Medicare Beneficiary Identifier (MBI) or Health Insurance Claim Number (HICN) can be populated for FA record layouts currently requiring submission of an HICN. CMS also indicated that New Member Layout should be populated to include only enrollees for which the plan does not utilize prior claims history.

Have questions for CMS? Email the Parts C and D mailbox at part_c_part_d_audit@cms.hhs.gov or the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov.

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.