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Billing the Patient’s Plan or Billing the Local Affiliate: Difficulties for Home Infusion Providers Servicing Patients of National Corporations

A recent trend has emerged for home infusion providers seeking to service local patients who may be employed by, or receive healthcare coverage through, a large organization headquartered out of state.  When servicing the local patients, home infusion providers are often instructed to submit major medical claims through the local affiliate of the health insurer, despite the fact that the patient might have a plan issued through another affiliate of...

Pharmacies Must Use Caution When Dealing with Third Party Auditing Companies

Over the past few years, PBMs have increasingly hired third party companies – such as SCIO, Xerox, Conduent or others – to conduct pharmacy audits. Many times, these companies are compensated based on the amount of money they recoup on behalf of the PBM (thus, they are incentivized to find as many discrepancies as possible). They are given very little training and certainly are not made aware of applicable audit...

Little Known and Under-Utilized Tool Enables Pharmacies to Demand Network Terms and Conditions for Medicare Part D Networks

Too often, pharmacies are faced with the difficult proposition of seeking admission into Medicare Part D networks. With new and evolving pharmacy business models, along with ever-changing and contracting pharmacy networks, it can be challenging to determine the appropriate network(s) to seek access to. This can be further complicated by PBMs routinely seeking to push pharmacies into general "retail pharmacy" networks, while restricting access from networks that provide more opportunity...

2019 Industry Outlook: What State Pharmacy Associations and Pharmacy Stakeholders Need to Know

With the November elections looming, the policy environment for pharmacy issues hangs in the balance. Who will control the halls of Congress as well as the state legislature will be key in determining the pace of pharmacy legislation. Over the last several months we have seen several positive developments for pharmacy, including clawback legislation; media pressure on PBM transparency; and other industry groups, such as the National Council of Insurance...

The California Insurance Commissioner’s Suit Against AbbVie Highlights Lurking Risks Under State Insurance Fraud Prevention Acts

Earlier this week, the California Insurance Commissioner filed a wide-ranging lawsuit against AbbVie, alleging classic illegal kickbacks to physicians as well as an intricate network of "nurse ambassadors" designed to improperly boost prescriptions for Humira, and seeking over $1.2 billion in damages.  Apart from representing a growing scrutiny on pharmaceutical manufacturers and other ancillary providers supplying nursing services allegedly in an effort to supplant the role of the prescribing physician,...