Topic: Part D

A Christmas Wish List for Claims

Debra Devereaux

Here’s what I am wishing for all our health plan clients….an uneventful start to the 2015 Plan Year. By that I mean that all the prescription claims that should adjudicate without rejecting actually do, and the claims that should not pay, reject as expected. Either the beneficiary leaves the pharmacy with their medication or the pharmacist is alerted that there is a potential problem with the dose of the medication. Here are some of the issues that we have found from our reviews: Read more

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Medicare Secondary Payer – A Simple Process with a Big Impact

Christine Tobin

We’ve heard many organizations say, “We do MSP” or “MSP, it’s easy, we’ve got it covered”. MSP processing may not be rocket science but it’s a regulated process with steps that need to be executed correctly. The MSP transactions that your organization submits directly affect the monthly payment to your Plan and impact your financial reports. Your organization needs to have a confidence level that is equipped with the proper tools to be efficient and compliant, and most importantly feel confident that the financials related to MSP are accurate.

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The Good, the Bad and the Ugly in Medicare Advantage

John Gorman

In the last two weeks there’s been good, bad and ugly news for Medicare Advantage (MA) plans.  On one hand, the program has never been stronger and quality metrics are surging in the right direction; on the other, the industry is sucking it up on following the rules of its biggest customer, the Centers for Medicare and Medicaid Services (CMS).

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They Still Don’t Like It

Debra Devereaux

In the October 8, 2014 memo entitled “Contract Year 2014 Part D Formulary Administration Analysis (FAA)”, CMS reiterates their concern with the accuracy of formulary coding. For the April 2013 analysis, 9 out of 88 (10.2 %) plan sponsors were found to have failed FAA, meaning that greater than 20% of the sampled rejects were determined to be inappropriate. The parameters for the 2014 FAA are: Read more

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The 2015 Ratings are In: Have the Stars Aligned?

Melissa Smith

The Centers for Medicare & Medicaid Services (CMS) has released the 2015 Medicare Advantage Star Ratings, and the Stars seem to be aligning with CMS’ goals of the Star Ratings program.  For the 40% of Medicare Advantage plans earning at least 4 Stars this year, and thus qualifying for Quality Bonus Payments, these newly-released Star Ratings illustrate the value of health plans’ investments in clinical innovation and quality improvement within Medicare Advantage product offerings.

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Part D Rejected Claims Continue to be Important Monitoring for CMS

Wayne Miller

Rejected claim analysis is a year-round activity with special emphasis that should begin before January. Are you confident in your current process to review and identify non-compliant rejected claims?

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It’s a Marathon – Not a Sprint

Debra Devereaux

Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here’s the rub:

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