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Topic: Part D
The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics: Read more
At the beginning of this week, Democrats and Republicans came to an agreement as to how to fund the government until September. Despite largely circumventing the demands of the White House, President Trump is expected to sign the bill.
The Gorman Health Group 2017 Forum concluded last week in New Orleans with over 200 of our closest clients and partners. As we enter our 21st year, we returned to where it all began for us, with a little startup called Peoples Health, our first and closest client who now dominates southern Louisiana. The Forum ended the day JazzFest 2017 began, so many of us stayed to enjoy the festival and the best of New Orleans heritage and culture.
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:
Perhaps a Visit to the Physical Therapist Is in Order – Make Sure Your CDAG Process Is Not a Weak Spot
Coverage Determinations, Appeals, and Grievances (CDAG) remain a compliance Achilles heel for many Part D sponsors. The Centers for Medicare & Medicaid Services (CMS) has noticed! Challenges with interpreting CMS regulations and guidance and operational restrictions have the potential to create a very costly gap. CMS is increasing scrutiny of this area in 2017.