The Centers for Medicare & Medicaid Services (CMS) released an HPMS memo on August 20, 2019 providing an overview of the upcoming changes to program audits through 2021. These changes…
On February 5, 2020, the Centers for Medicare & Medicaid Services (CMS) announced it will not be publishing a Call Letter for 2021. Rather, CMS is codifying guidance typically published…
In 2019, Medicare introduced new policies for opioid prescriptions in the Medicare Part D prescription drug program to encourage pharmacies, prescribers, and Medicare drug plans to work together with the…
Independent Review Entity (IRE) Transparency Initiative Plans are continuously looking for data to better understand their appeals outcome. The IRE transparency initiative provides plans with several more tools. During the…
From July 16-18th over 100 investigative minds met at the annual CMS Fraud Conference in Miami, Florida to talk about current fraud schemes, emerging schemes, data analytics and how to…
Sometimes, life happens. Turnover, volume increases, changing guidance, system changes or audit issues that require remediation all can create situations where a Plan or PBM needs expert resources fast. And…
2019 is already off to a blazing start with the implementation of Medicare Part D plans’ new opioid edits as well as 2020 formulary development. While plans are already preparing…
Many Medicare Plans may believe compliance with the ten-year record retention requirement is a slam-dunk. However, plans are often tripped up in audits because their first-tier and downstream entities do…
Along with the new year also comes a new CMS requirement known as the Preclusion List. This requirement was adopted in the April 2018 final rule as an alternative to…
One of the surprises in the release of plans’ Star Ratings results for the 2019 open enrollment season was that Star Ratings around Part D adherence scores, on average, slipped.…