By James
Gutman - April 28, 2015
If it’s true that “fool me once, shame
on you; fool me twice, shame on me,” then Medicare Part D plans might be
feeling a lot of shame right about now. This is because even though CMS has
made it super-clear that one of its highest priorities is ensuring pharmaceutical
access to Part D beneficiaries, plan sponsors keep getting fined substantial
amounts by the agency for violations turned up in plan audits related to access
to Rx drugs.
Specifically, there have been 12 civil
money penalties (CMPs) related to drug access imposed by CMS just since the
beginning of the year, with all but two of them for at least six-figure
amounts. The highest of those amounts for “garden variety”
pharmaceutical-access violations is the $689,600 Citizens Choice Health Plan
was assessed, but that’s not counting the $1 million fine CMS levied against Aetna Inc. this
month for erroneously listing nearly 6,000 retail pharmacies as in network
for Part D for the 2015 Annual Election Period. The apparently unintentional
Aetna violations resulting from its moves to narrower pharmacy networks
prompted 3,767 complaints filed by Part D plan members with CMS.
Among the other more common violations
CMS has been finding in audits is failing to adjust for changes resulting from
new drugs coming on the market or formerly brand drugs going generic after the
Part D plans file their formularies with the agency. There are also not
furnishing transition supplies of pharmaceuticals to members who change plans,
using unapproved utilization-management techniques, not meeting time frames for
requested coverage determinations and misclassifying complaints as coverage determinations
or lumping appeals with grievances.
And it’s not that CMS hasn’t made clear
that this area is a priority because of the potential for harm to
beneficiaries. The agency last summer put out a “best-practices” memo outlining
what it’s found in audits and saying in no uncertain terms that it’s tired of
continuing to see these violations. Partly the issue is, as consultant John
Gorman, executive chairman of Gorman Health Group, LLC, points out, that the
Part D plans are using pharmacy benefit managers for Rx drug oversight, and
some of those PBMs are still finding out what’s involved in transitioning from
business-to-business to business-to-consumer organizations. There also are, as
Gorman says, “lots of moving pieces” plans have to maneuver to handle drug
access correctly. But as ATTAC Consulting CEO Steve Arbaugh notes, many of the
problems could be avoided with some common sense, such as furnishing specific
reasons for coverage denials and suggesting alternatives, along with monitoring
pharmacy claim rejections and doing mock audits.
So why do you think there still
apparently are so many problems for Part D plans with pharmaceutical access? Is
it that the plan sponsors aren’t keeping the PBMs on a tight-enough leash? Is
it that lawyers are advising plans not to furnish too much information to
beneficiaries on denials? Is a big factor that making these determinations
still is confusing, especially considering all the changes occurring in the Rx
drug market each year? And is there one additional factor, as Gorman suggests,
that “scores always get settled in the second term of a presidency” and that
the Obama administration thus may find it more feasible to achieve its policy
goals on pharmaceutical access via regulation than via legislation?
No comments:
Post a Comment