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PHARMACY ALERT: Be Cautious of OIG Inquiries into Your Pharmacy’s E1 Transaction History

During the Implementation of Medicare Part D, the Centers for Medicare & Medicaid Services (CMS) created a mechanism to allow pharmacies to determine eligibility for Medicare Part D benefits. The process is called an E1 transaction and confirms the Medicare Eligibility of an individual after submission of basic demographic information. Recently, Frier Levitt has become aware that the Department of Health and Human Services (HHS), Office of Inspector General (OIG)...

Pharmacy Audit Checklist: Considerations When Preparing for PBM Audits

From recoupments and network terminations, to governmental investigations, pharmacies face serious PBM risks when issues that arise in audits are not properly addressed. Preparation and preventative measures are key to ensuring a positive audit result. Even though CMS has provided a pharmacy audit checklist, there are some other issues pharmacies should consider before any PBM audit: Common PBM Audit Issues: Is your Pharmacy properly contracted with each PBM based on...

NADAC Pricing Leads to Unreasonably Low Medicaid Reimbursement: What Can a Pharmacy Do?

There has been perhaps nothing more detrimental to pharmacy margins in the Medicaid arena than the implementation of the National Average Drug Acquisition Cost (NADAC) pricing benchmark. Indeed, many pharmacies conducting business in states that utilize NADAC pricing have seen their reimbursement rates plummet, oftentimes to rates at or below acquisition cost. What's worse for independent pharmacies, NADAC pricing has seemed to gain momentum and has recently been adopted by...

Hot Topics in Specialty Pharmacy Law: PBM Prescription Trolling, HUB Arrangements, DIR Fees Update, Opioid and Naloxone Laws, and NADAC Pricing

    Download the webinar slides. The specialty pharmacy industry has dramatically changed over the past few years and is now one of the fastest growing sources of revenue in the prescription drug marketplace. As a result, payers and PBMs have adopted numerous policies and tactics to maximize PBM profits and drive patient traffic away from independent pharmacies. These policies and tactics, along with current healthcare regulations, have created challenges...

The Impact of DIR Fees on 340B Relationships Between Contract Pharmacies and Covered Entities

The impact of Direct and Indirect Remuneration ("DIR") fees on the specialty pharmacy industry cannot be overstated and has been widely reported in White Papers and industry news reports. However, the impact of DIR fees on the 340B sector is only now being realized. In the first of a series of articles, Frier Levitt explores the basics of DIR Fees as applied to 340B. The 340B Drug Discount Program ("340B")...