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- Bruce Bell on Why Medicare Advantage is Here to Stay
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- Naomi on What Sequestration Could Mean to Medicare Advantage Claims Payment
Topic: Part D
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
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.
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
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?