Topic: Part D

Benefit Administration Testing – From a Compliance, Audit, and Best Practice Perspective

Miru Monte

In 2016, 41 million individuals (72 percent of all Medicare beneficiaries) were enrolled in Medicare Part D. Of those enrolled, 60 percent were in stand-alone Prescription Drug Plans (PDPs), and 40 percent were in Medicare Advantage Prescription Drug plans (MA-PDs). Plan sponsors must adjudicate pharmacy claims for the Part D benefit in accordance with their Centers for Medicare & Medicaid Services (CMS)-approved formulary and Plan Benefit Package (PBP) bids.

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Opioid Abuse: A Growing Compliance Risk for Medicare Advantage Plans

Debra Devereaux

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.

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A Decade of Lagging Medicare Part D MTM Services

Wayne Miller

After a decade of Medication Therapy Management (MTM) programs, nearly every Medicare Advantage plan still misses a huge opportunity to capitalize on it.

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Rejected Claims Review–You Gotta Do It!

Debra Devereaux

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

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Big Changes to Medigap in 2020 = A Seismic Event in Senior Markets Now

John Gorman

A little section in the Medicare Access and CHIP Reauthorization Act (MACRA) is bringing big changes to Medicare supplemental insurance, also known as Medigap, bought by more than 12 million seniors to help fill in the coverage holes in traditional Medicare. In the vast majority of cases, Medigap purchasers augment their coverage with a Medicare Part D Prescription Drug Plan (PDP). That means MACRA’s changes will cause a seismic event in senior markets – Medicare Advantage, Medigap insurers, and PDPs – nationally, starting now.

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10 CMS Program Audit Risks

Regan Pennypacker

Program audits and oversight activities must be designed with many factors to balance: accuracy, consistency, efficiency, and in an effort to be least disruptive to a plan sponsor. Correspondingly, a plan should be tailoring its response to these audits with those same factors in mind. My colleague Deb Devereaux and I outline ten common risk areas we observe in plans large and small. Read more

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The True Path to Improving the Medicare Member Experience

John Gorman

I’ve been struck lately by two new research reports that demonstrate improving the member experience is the top challenge facing Medicare Advantage plans. First, JD Power is out with its 2017 Medicare Advantage Satisfaction Rankings. Among the results: Read more

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