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Five Things Providers Must Know About Express Scripts’ Newly Implemented DIR Program

Specialty pharmacies and physician dispensers will experience a drastic reduction in Medicare net reimbursement rates from Express Scripts, Inc. (ESI) beginning in the plan year 2020. ESI has implemented a DIR Fee program in certain Medicare Part D networks, likely including Cigna following its purchase of ESI. ESI has followed the lead of other major PBMs. Declining net reimbursement rates are the number one Provider concern nationally. Here are the...

New CMS Rule: Program Integrity Enhancements to the Provider Enrollment Process

The Centers for Medicare & Medicaid Services (CMS) recently announced a final rule entitled "Program Integrity Enhancements to the Provider Enrollment Process." The new rule, which will go into effect on November 4, 2019, requires Medicare, Medicaid, and Children's Health Insurance Program (CHIP) providers and suppliers to disclose any current or previous direct or indirect "affiliations" (as specifically defined by CMS) with another provider or supplier that: has uncollected debt...

Dental Practice Agrees to $10,000 Settlement for Potential Social Media HIPAA Violation

Last week, the Office for Civil Rights (OCR) announced a settlement related to allegations that a dental practice disclosed protected health information on its Yelp review page. The original complaint, filed in 2016, alleged that the practice impermissibly disclosed a patient's last name, details of her treatment plan, insurance, and cost information when responding to the patient's negative review. An OCR investigation revealed that this was not the only instance...

Generic Effective Rate (GER): A New Type of Post-Sale Clawback by PBMs

*This blog originally appeared on healthcare.buzz  Post-sale clawbacks by Pharmacy Benefit Managers (PBMs) have become a huge issue for independent pharmacies. Traditionally, these include audit-associated recoupment and performance-based recoupment such as Direct and Indirect Remuneration (DIR) fees that are charged to the pharmacies. Recently, another type of post-sale recoupment has taken the center stage and has caused grave financial harm to the independent pharmacies. PBMs call it Generic Effective Rate...

Plan Sponsor ALERT: PBMs Should Be Held Accountable for Opioid Crisis

It is no secret that the opioid crisis has caused devastating impacts upon patients and their loved ones as well as the overall healthcare industry. Since the inception of the crisis, public Plan Sponsors including state agencies and municipalities, have brought countless claims against the opioid manufacturers, distributors, and wholesalers. However, until recently, plaintiffs have failed to apprehend the critical role played by Pharmacy Benefit Managers (PBMs) in the on-going...