CMS announced they will be performing a 2021 transition of care audit using the Transition Requirements Analysis (TR) that was piloted back in 2019. Although the 2019 TRA did not identify any apparent concerns, very few plans will be exempt from this analysis. It is highly recommended that plans invest time and resources to conduct their own assessment using CMS’ same steps and perspective to determine if is a possible compliance risk to the organization.
Within the analysis, CMS will use the plan’s Prescription Drug Event (PDE) data to identify members who had previously filled a maintenance medication in 2020 that was removed from the plan’s 2021 formulary. CMS will then identify members who did not refill these medications, or a therapeutic alternative medication, within the first three months of 2021 to determine if the plan failed to afford a transition fill of the medication. Ten members per parent organization will be selected and the plan sponsors will be required to provide additional information or justification to why the member did not continue their therapy or was denied a transition fill.
Traditionally, plans monitor rejected claims to identify possible transition of care issues. With this new analysis, plans should also take a different perspective and use the following steps to imitate the analysis:
- Identify maintenance medications that went non-formulary in 2021
- Identify members who had a prior fill of those medications within at least the last 108 days of 2020
- Review these impacted members 2021 claim experience for the impacted medications and determine if there were any situations where a transition fill was not afforded
Although it is early in the 2021 plan year, it is important for plans to take inventory of these situations to ensure they are prepared to provide a response to CMS once their tickets are received. BluePeak has several plans that they support with both paid and rejected claim monitoring and can help support any plans with this analysis to determine if there is a transition of care concern with these medications.