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$4 Million Settlement Latest in Growing Trend of Patient Assistance Program Scrutiny

On November 20, 2019, The Assistance Fund (TAF) agreed to pay a $4 million settlement and enter a three-year integrity agreement, to resolve allegations of False Claims Act violations related to paying impermissible kickbacks to Medicare beneficiaries. This represents the third settlement involving a patient assistance fund in the past month, indicating a trend in enforcement action. TAF operated assistance programs to assist patients, including Medicare beneficiaries, with co-payment, co-insurance,...

Frier Levitt Announces Plan Sponsor Practice Group for PBM Contracts

National boutique Healthcare and Life Sciences law firm Frier Levitt announced today the establishment of a Practice Group focused exclusively on the representation of Plan Sponsors—including Self-funded Plans (employers, labor funds, public sector, federal), Health Plans (commercial, Medicare, Medicaid, and Exchange Plans), and Regulated Markets (Medicare, Medicaid, Public Health Exchanges)—regarding Pharmacy Benefit Manager (PBM) contracts and issues they may experience working with PBMs. Frier Levitt's Plan Sponsor Practice Group works...

Frier Levitt Secures Reversal of Pharmacy Termination from Major Plan Sponsor

Frier Levitt recently represented a New York pharmacy that had suffered a termination without adequate notice directly from a major plan sponsor. The plan stated the termination was in light of recent guidance from CMS and the Office of Inspector General of the Department of Health and Human Services (OIG) related to alleged questionable billing practices related to certain lidocaine creams and topical treatments, and it sought to identify and...

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...

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...