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PBMs Targeting Manufacturer Coupons and Copay Assistance in Pharmacy Audits

PBMs have increasingly begun targeting the usage of manufacturer sponsored coupon programs and copayment assistance programs in both desktop and on-site audits of pharmacies. As a result of these audits, PBMs are alleging discrepancy findings, and recouping money from pharmacies, based on a number of different factors, including, but not limited to, the usage of a coupon on a non-FDA approved drug. Of course, there are certain limitations on when...

Is Your MAO Effectively Capturing and Processing Medicare Advantage Risk Adjustment Data?

Effectively identifying and processing Medicare Advantage (MA) risk adjustment data is no simple matter – it requires extensive experience in data science, claims and encounter data analytics, actuarial science, CMS regulatory and sub-regulatory guidance, and up-to-date, HIPAA-compliant risk adjustment software platforms. Without these skills and technology, valuable MA risk adjustment data that would otherwise be submittable to CMS and generate increased revenues for your organization may be overlooked, ignored or...

Missouri Healthcare Provider Alert: Out-of-Network Providers Given New Tools to Collect Fair Reimbursement from Insurance Companies

On May 18, 2018, the Missouri state legislature passed a bill benefitting Out-of-Network (OON) healthcare providers including physicians, hospitals, dentists, podiatrists, chiropractors, pharmacies, ambulance service providers, or optometrists. The bill directs insurance companies to directly pay OON Providers when services were authorized by the insurance company and creates obligations for insurance companies to make reasonable payment for unanticipated out-of-network care even if not granted a prior authorization. The bill still requires...

Congressional Subcommittee on Health Holds Hearing Examining the FDA’s Authority in the Implementation of the Compounding Quality Act

The United States House of Representatives' Subcommittee on Health recently held a hearing examining the FDA's ever-expanding role in ensuring the enforcement of the Compounding Quality Act. Against the backdrop of a fatal meningitis outbreak caused by a compounding pharmacy in Massachusetts which infected over 750 patients in 2012, Chairman Greg Walden (R-OR) emphasized that, with respect to 503B outsourcing facilities, the FDA "must ensure that outsourcing facilities do not...

Former Aetna Medical Director Admits to Company-Wide Prior Authorization Misconduct Under Oath

Yesterday, CNN posted an exclusive article regarding the regulatory fallout stemming from the recent testimony given under oath by one of Aetna's former medical directors. During his sworn testimony, a former medical director admitted to never having reviewed patients' medical records during appeals of coverage determinations, stating that he was merely following "Aetna protocol." The testimony was given by the former Aetna medical director in connection with a patient's longstanding lawsuit brought...