Pharmacy benefit consulting 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Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program.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 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

It’s Time to Make your 2021 CMS Star Ratings Better Than Ever

September 22, 2019September 23, 2019

The Centers for Medicare and Medicaid Services plans to release its 2020 Star Ratings in October. Whether you received four or five stars or lower, the clock is ticking if you want to have a positive impact on your health plan’s rating next year.

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. An experienced Medicare plan consultant like the team at Tier 1 Pharmacy Consulting can help you prepare for rating season – and ensure the best outcome possible.

What are Star Ratings?

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.

Here are a few tips going into 2021.

If it’s broken, fix it – with help. If your health plan has been using the same tactics year after year and not seeing a ratings increase, it’s time to change your strategy. Look at your data, measure it, and seek an outside consultant to give you an objective picture as well as an action plan moving forward.

Capture the right data. Many plans fail to earn four stars because they don’t capture HEDIS, PDE, and other important information. It takes time, and health plans have enough going on during a busy fourth quarter. Hire someone to look at issues and resolve them for you – before it’s too late.

Invest in CAHPS. CAHPS are weighed more heavily now, making up a huge portion of the overall Star Rating. Make sure your CAHPS performance is as strong as your HEDIS investment. If you need, look for someone who can help make sure your CAHPS performance is solid.

Find a Star Ratings expert. As we mentioned in the three previous tips, there’s a lot of work to be done and a lot at stake. Why risk earning a low Star Rating due to lack of time, expertise, oversight, experience, or knowledge? The right consultant can make the difference between one and three stars and beyond.

The Time is Now

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 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.

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.

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

What can Tier 1 Do for Your Health Plan?

May 14, 2019

Take a second look at what we do.

Tier 1 Pharmacy Consulting prides itself on adding value to their clients’ businesses not only through the services it offers, but also by engaging in frequent knowledge-sharing via its online blog. Regulations, standards, and methods of operation in the overlapping worlds of health care, health plans, and pharmaceuticals can shift in the blink of an eye. If health plans don’t stay abreast of the latest laws, the penalties can be severe. Tier 1 takes their responsibility of educating and guiding its clients through complex guidelines seriously—and if you’re new to us, clicking through our blog archives will demonstrate how the depth and breadth of Tier 1’s knowledge base can have a meaningful impact on your health plan—and your bottom line.

This week, we’re shining the spotlight directly on Tier 1 and the many ways this company can help health plans do their best work for their own clients while remaining in compliance. Read on to find out why our thought leadership is just one reason to partner with us.

Founded with the Client in Mind: Tier 1’s Story

Tier 1 was founded in order to meet one core goal: Help health plans across the country to develop effective strategies and improve health plan outcomes. Each and every staff member from Tier 1 assigned to a client is an expert at making great plans even better, and improving plans that haven’t yet met their own goals due to lack of time or resources.

“I created Tier 1 because I know firsthand how complex the pharmacy and health care industries can be,” comments founder and CEO Brent Hiley. “I’ve spent my entire professional life as a pharmacist, and subsequently a pharmacist benefit manager—these experiences gave me the insights and expertise needed to help health plan administrators navigate through a complicated and heavily regulated world.”

Tier 1’s mission and methods are directly inspired by Mr. Hiley’s first-person experience. The company recognizes the importance of health plans in the larger world of health care—when operating effectively and efficiently, they can help cut costs through patient adherence, drug utilization, and regulatory compliance. The most effective health plans are able to seamlessly integrate specific requirements—and Tier 1 helps their clients accomplish this through multiple avenues of service, ranging from the simple to the complex.

Collaboration, Insight, Expertise: How Tier 1 Can Help Your Health Plan at Every Stage

Tier 1 offers a full suite of services to its health plan clients. These services include interim management support, application support, audit support, clinical strategy, compliance, delegation oversight, operations, risk assessment, policy writing and material review, and RFP initiatives. Much of what Tier 1 does is geared towards taking the substantial workload off client’s shoulders so they can focus more on the needs of their patients. Other services focus specifically on a simple and universal goal: saving clients money. By hiring an external consultant to conduct audits, as just one example, health plan administrators can save themselves thousands of dollars—and a similar number of headaches—down the line.

“Simply put, Tier 1 employees are experts in streamlining your health plans so that you can make the most of your bottom line without sacrificing customer care,” comments Mr. Hiley. “We are driven by our client’s satisfaction—and have happily helped thousands of health plans meet their needs effectively.”

About Tier 1

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

CMS proposes updates to audit Civil Monetary Penalties

March 28, 2019March 29, 2019

Medicare plans and pharmacy teams are being heavily scrutinized by the Centers for Medicare and Medicaid Services – now more than ever before. The changes CMS has implemented for 2019 as well as upcoming proposed changes for the next few years suggest that plans are more likely to be audited than not.

An audit is certainly a black mark on a health plan. It’s stressful. And, it can be expensive.

CMS audit penalties have cost health plans as much as $375,000. In mid-March, the agency released a proposal updating its civil monetary penalty listings for last year’s audits – and the fines are all higher per enrollee. An overview:

Per Enrollee Penalty Amounts in 2017 and 2018

– Standard Penalty: $200

– Aggravating Factors: $100

– Untimely/Inaccurate Beneficiary Communications Standard Penalty: $25

– Untimely/Inaccurate Beneficiary Communications Aggravating Factor: $15

Penalty Amounts for 2019-2021

– Standard Penalty: $212

– Aggravating Factors: $106

– Untimely/Inaccurate Beneficiary Communications Standard Penalty: $27

– Untimely/Inaccurate Beneficiary Communications Aggravating Factor: $16

Why is CMS raising the fines? That remains to be seen. Among other things, officials take into account inflation and cost-of-living adjustments.

CMS plans to release a final plan in April.

Audits are usually conducted once every between three to five years. There are different types, including 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.

It’s important to be ready at all times for an audit – especially if your health plan has performance issues or has faced CMS oversight in the past.

Plans that do not have a vigorous auditing and monitoring program are at risk of non-compliance with CMS regulations – and resulting fines. Being prepared will help plans identify and respond to potential gaps and address them as quickly as possible. The audit process is extensive, and tough to do when you’re trying to run your plan every day. And, don’t forget, plans only have three weeks from the time they receive an audit notice to be ready for it to get underway. You’re going to need help – and that’s where we come in.

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.

Get in touch today – before an audit notice lands on your doorstep and costs your plan hundreds of thousands of dollars or more.

About Tier 1

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