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PHARMACY ALERT: PSAOs Amending Pharmacy Participation Agreements

Recently, pharmacies have been finding that Pharmacy Services Administrative Organizations (PSAOs) are amending their pharmacy agreements. Pharmacies should closely review these revisions to determine how their rights may change under the new contract amendments. Reviewing there visions is made even more important due to numerous PSAOs seeking to withhold moneys for GER and DIR reconciliations at the close of 2018. Often, PSAO pharmacy amendments become binding if a pharmacy does...

PHARMACY ALERT: Pharmacy Obtains TRO Against PSAO Preventing GER Withholding

Epic Pharmacy Network, Inc. (Epic) was ordered today to turnover any funds that it has already withheld and refrain from withholding further payment to a pharmacy in its network as a result of a Generic Effective Rate (GER) adjustment once a security bond is in place by the moving pharmacy.  Pharmacy Services Administrative Organizations (PSAOs) recently sent out "Notice of GER Deductions" to pharmacies in its network advising that the...

Why Out-of-Network Providers Need a Limited Power of Attorney from Patients After Recent Appellate Court Decision

Many OON providers utilize assignment of benefit forms so that a provider can be paid by an insurance company directly or the provider can dispute nonpayment or under payment instead of this action being taken by the patient. However, last week in American Orthopedic & Sports Medicine, v. Independence Blue Cross Blue Shield; Horizon Blue Cross Blue Shield of New Jersey, the 3rd Circuit Court of Appeals determined that anti-assignment...

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...

California Pharmacies Set to Suffer Retroactive Medicaid Clawbacks

California pharmacies must act now to prevent 18 months of retroactive reduction in Medicaid payments set to be collected from pharmacies in late 2018. Without taking action now, pharmacies may be unable to shoulder the burden of historical claims adjustments for all California Medicaid claims after April 1st, 2017. In 2017, the Centers for Medicare and Medicaid Services (CMS) required state Medicaid reimbursement to transition from an Estimated Acquisition Cost...