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»  Posts By   September 2015 

More States Follow MAC Transparency Act Trend, Enacting More Stringent PBM Regulations

Over the past several years, Maximum Allowable Cost or “MAC” pricing has become especially prevalent in prescription drug reimbursement frameworks, and has evolved as a preferred method of reimbursement among pharmacy benefits managers. Generally speaking, the MAC price has been set by PBMs as the upper limit or maximum amount that a plan will pay for generic drugs and multisource brand name drugs. MAC prices have historically been challenged for their...

OIG Recommends CMS Take Action to Prevent Overpayments for Outpatient Drugs

Medicare Part B covers the cost of outpatient drugs for beneficiaries. To administer benefits, Centers for Medicare and Medicaid Services (CMS) contracts with Medicare contractors, who determine reimbursement amounts and pay claims. In an effort to reduce contractor payment errors and overpayments, CMS implements various initiatives, which are meant to identify and address billing and coding errors made by providers, before Medicare contractors reimburse their claims. As part of its...

The Status of Per-Click Restrictions Under the Stark Law

On June 12, 2015, the U.S. Court of Appeals for the District of Columbia Circuit issued a decision in the Council for Urological Interests v. Burwell case that could have a significant impact on the regulatory prohibition on per-click equipment leases under the Federal Stark Law. The regulation in question prohibits equipment leases that charge a hospital for each use of the equipment, or a “per-click” use, and the regulation instead...

OIG Advisory Opinion Allows Clinical Trial Sponsor to Subsidize Copayments

Paying subsidies to clinical research subjects has long been viewed as a clear violation of the Federal Anti-Kickback Statute (AKS). However, in a recent Advisory Opinion, the U.S. Department of Health & Human Services, Office of Inspector General (OIG) stated that it would not impose administrative sanctions on a device manufacturer that subsidizes copayments for Medicare beneficiaries participating in a clinical trial sponsored by the manufacturer. Centers for Medicare &...

Frier Levitt is Successful in Reversing Another PBM Termination

Frier Levitt is pleased to announce its success in reversing yet another PBM termination decision issued against an independent community pharmacy. The PBM had moved to terminate the contract of a well-regarded community pharmacy. If the pharmacy lost this contract, the pharmacy would have been forced to close its doors. Frier Levitt was able to negotiate a Corrective Action Plan with the PBM which allowed the pharmacy to remain in...