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»  Posts By   January 2018 

Don’t Come Up Short: Avoiding Inventory Shortfall Discrepancies When Purchasing Directly from Pharmaceutical Manufacturers

Pharmacy benefit managers (PBMs) have audited pharmacies on drug purchases for some time, seeking to compare total claims billed to the PBM versus quantities purchased by the pharmacy. When quantities billed to the PBM exceed the demonstrated inventory on hand by the pharmacy, the PBMs issue discrepancy findings and seek to take back large amounts from pharmacies. One trend that has begun to crop up more often in recent months...

Government Tries to Reframe Materiality in False Claims Act: What It Means for Providers

As the overseer of health benefits for millions of Americans, the Federal Government has a vested interest in ensuring the legitimacy of claims submitted for payment to Government Healthcare programs, such as Medicare, Medicaid, and Tricare. The False Claims Act (the "FCA" or the "Act"), which is perhaps the Government's strongest tool in ensuring the validity of claims, is a civil statute which carries harsh penalties for knowingly submitting, or...

CMS Announces Bundled Payments for Care Improvement Advanced (BPCI-Advanced) Initiative

Recognizing that bundled payments have been a successful value-based care model, Centers for Medicare & Medicaid Services (CMS) has recently announced the details of its new voluntary bundled payment program, Bundled Payments for Care Improvement Advanced (BPCI-Advanced).  The BPCI-Advanced has multiple qualifications and features worth noting, including: Eligible Participants: Non-conveners: Acute Care Hospitals (ACH), Physician Group Practices (PGP) Conveners: Participants who bring downstream providers, "episode initiators," together (ex. may include...

New Jersey Finalizes New Rule to Set a “Gift Ban” to Cap Physician-Pharma Relationships

On December 22, 2017, the New Jersey Attorney General finalized new rules governing physician interactions with pharmaceutical companies. Titled "Limitations on and Obligations Associated with Prescriber Acceptance of Compensation From Pharmaceutical Manufacturers," the Rule sets a $10,000 yearly cap on the amount, through contracts and payments, that a prescriber may accept from manufacturers in a calendar year for "bona fide services." Additionally, the Rule subjects physicians to a cap on...

Independent Pharmacy Owners Have Spoken: Recent Pharmacy Surveys Identify Top Policy Priorities and Frier Levitt Has Practical Solutions

The National Community Pharmacy Association (NCPA) recently released the results of a survey of its independent pharmacy owners to identify their top policy priorities for 2018. According to the survey, independent pharmacies ranked four key desires: (1) elimination of retroactive pharmacy DIR fees; (2) ensuring MAC transparency to address delays in payment rate updates and appeals processes; (3) obtaining reasonable Medicaid pharmacy reimbursement; and (4) gaining access to Medicare Part...