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The Voice of Debra Devereaux
What is the definition of medication reconciliation?
The Joint Commission defines medication reconciliation as the process of comparing a patient’s medication orders to all of the medications the patient has been taking in order to identify and resolve medication discrepancies.1
Two recent Centers for Medicare & Medicaid Services (CMS) Health Plan Management System (HPMS) memos clarified supplemental benefit parameters and the rules for uniform distribution of those benefits (“Reinterpretation of the Uniformity Requirement,” April 27, 2018, and “Reinterpretation of ‘Primarily Health Related’ for Supplemental Benefits,” April 27, 2018). Supplemental benefits were defined as “an item or service (1) not covered by Original Medicare, (2) that is primarily health related, and (3) for which the plan must incur a non-zero direct medical cost.” Of primary interest to health plans in the immediate future as bids are due June 4, 2018, are the following: Read more
“There’s no harm in hoping for the best as long as you’re prepared for the worst.”—Stephen King
Opioid overutilization and the corresponding public health crisis are ubiquitous in the daily news. In September 2017, the White House declared the opioid drug crisis was a national emergency. A presidential commission report described the opioid epidemic death rate as “September 11th every three weeks.” The map below, found on Consumer Protect, illustrates the number of opioid prescriptions by state in 2016.
The question arises from almost every client, “Why do we have to do daily rejected claims review?” The answer is that there is no better way “to take the temperature” of Part D compliance than rejected claim reviews. Everything that can and will occur happens at Point of Sale. At a minimum you can detect problems with the following: Read more
It’s impossible to achieve reasonable and prudent member care management in a vacuum. The three-legged stool supporting care management includes medical management, risk assessment, and medication therapy management. The care manager cannot make reasonable decisions about a member’s care unless he or she has knowledge of the member’s medical management history and current status, medication history and current status, and diagnostic history and current status based on risk assessment.
At the beginning, it all sounds great…the PowerPoint presentation was informative, and the staff who came to present all seemed very competent and caring with a lot of integrity. Then the negotiations begin, and there’s a lot of back and forth and he-said/she-said, and you give up. That is not a great strategy for getting a Pharmacy Benefit Manager (PBM) contract that meets your financial, compliance, and Star Ratings goals. You must have a letter of agreement if you are implementing a new plan, but the contract negotiation may stretch into the latter part of third or fourth quarter. You are better off taking your time, getting your own legal counsel review, and staying true to your plan goals.