The Achilles Heels of Part D in Program Audits: FA and CDAG Administration

Caron Wingerchuk

This may seem like the movie “Groundhog Day,” but Formulary Administration (FA) and Coverage Determinations, Appeals, and Grievances (CDAG) continue to hobble plan sponsors’ Centers for Medicare & Medicaid Services (CMS) program audit results. Failure to properly administer their CMS-approved formulary continues to plague plan sponsors. As a result, enrollees experience inappropriate denials of coverage at the point of sale and were delayed access to their medications, never received their medications, or incurred increased out-of-pocket costs in order to receive their medications. Plan sponsors continue to be tripped up in the following areas of FA:

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Three Important Tips to Make Sure Your Bid Process Is Successful This Year

Diane Hollie

Now that applications are completed, it’s time to get started on developing bids for 2018. In our experience …

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First Month on the Job for Price and Verma Signals Big Policy Changes at CMS

Olga Walther

With Trump’s picks of Tom Price to head the Department of Health & Human Services (HHS) and Seema …

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Agent compensation changes in the Draft 2018 Medicare Marketing Guidelines

Betsy Seals

With the release of the Draft 2018 Medicare Marketing Guidelines (MMG), the Centers for Medicare & Medicaid Services …

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CMS Puts Plans on Notice with Recent Enforcement Actions

Regan Pennypacker

The Centers for Medicare & Medicaid Services (CMS) Program Audit reviews a subset of contractual requirements every year, …

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The Future of Medicaid under the “Three-Pronged Approach” to ACA Repeal

Olga Walther

This week, amidst contentious discussions about the Affordable Care Act (ACA) repeal, the new Department of Health & …

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Improving Your Plan’s Future Operations Through a Look Back into Your Members’ Experiences

Julie Billman

Open enrollment is over, and as we move through the first quarter of 2017, all kinds of problems …

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