Top 5 Tips to Prevent a Part D Transition Finding

Transition is highly scrutinized and frequently audited within the Medicare Part D program. For 2021, the Centers for Medicare & Medicaid Services (CMS) performed the Transition Requirements Analysis (TRA) to identify enrollees who were inappropriately denied a transition fill. BluePeak anticipates CMS will resume this audit in 2022. Additionally, if selected for a program audit, CMS will target up to 30 transition claim samples to perform a detailed audit on the sponsor’s transition process. For both areas, findings may result in CMS enforcement actions that include a civil money penalty (CMP), suspension of enrollment, and/or possible contract termination. Below is a list of action items that plan sponsors can take to prevent a transition finding.

1. Establish a 1/1 action plan

   1. Action Items: Outline an action plan to ensure adequate monitoring and oversight of 1/1 activities. Within the action plan, clearly outline staff who will be responsible for each area. Setup daily meetings to review monitoring, results, and any error remediation.
   2. Timing: Finalize by December
   3. Rationale: Plan for the worst, and hope for the best. When issues arise, there needs to be an immediate escalation process for a detailed assessment to outline next steps. Avoid ad hoc meetings and put placeholder meetings on the responsible staffs’ calendars.

2. Know the transition policy

   1. Action items: Thoroughly review and understand the plan’s transition policy. Review the current year’s policy and identify any possible changes for the new year. Understand how many days are allotted in a one month supply for retail and long-term care pharmacies. Ensure the claim adjudication system appropriately reflects any changes.
   2. Timing: Prior to year end testing
   3. Rationale: Transition policies are becoming more dynamic each year and plans need to ensure any changes are appropriately effectuated within the claim adjudication system.

3. Conduct Year End Testing

   1. Action Items: Thoroughly test and validate all formularies, benefits, and transition test conditions prior to 1/1. Utilize the same testing staff that are responsible for claim monitoring activities as they are most familiar with the plan’s benefit and setup options.
   2. Timing: Testing should be completed by mid-December.
   3. Rationale: This is the most proactive approach to mitigate formulary, benefits, and transition errors. There is no such thing as too much testing prior to 1/1. Any issues identified during the plan year will cause the plan to revisit their testing strategy to prevent issues from reoccurring in the future.

4. Validate new enrollees are setup appropriately prior to the start of the plan year

   1. Action items: Request a new enrollee list from the enrollment department and the PBM and perform a comparison for any differences.
   2. Timing: Perform this activity the last two weeks of the plan year to ensure the data is current and up-to-date.
   3. Rationale: Many transition findings are a result of a failure to setup new enrollees in the claim adjudication system. This approach is proactive and can prevent access of care situations.

5. Monitor rejected claims and transition letters daily

   1. Action items: Compare the CMS approved formulary to all formulary rejections and some administration rejections to identify inappropriate claim rejections. Rejections include non-formulary, quantity limits, prior authorization, step therapy, opioid naïve, and day supply rejections. Establish process to identify transition situations for new and continuing enrollees. Develop a process to review transition letters to ensure the letter is timely and accurate.
   2. Timing: At least daily
   3. Rationale: Formulary and administrative configuration errors will cause claims to process inappropriately during transition resulting in possible conditions. Ensure the person reviewing claims daily has a way to identify if the claim was for a new enrollee or continuing enrollee with a prior history of medication with a negative formulary change. CMS reviews all transition letters during program audits and it’s essential to ensure these letters are compliant to avoid a condition.