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Pro Pharma Announces MAC Pricing Solutions for Medicare/Medicaid Managed Care
Monitoring of Medicaid/Medicare benefits require timely interventions, including MAC compliance with State Medicaid MAC and the federal FUL. Part D variance in claim adjudication must be corrected more timely to avoid unnecessary penalties
“Clients can choose from design parameters based on which drugs and categories to include, manufacturer considerations, multiple bases of cost options (AWP, WAC, DP, U&C, Dispensing Fee. Newly included are NADAC & AAC when available)” , said Craig Stern, PharmD, MBA, President of Pro Pharma. “Pro Pharma can also assist with distribution (websites), maintenance, and pharmacy support" - Visit http://propharmaconsultants.com/
Health Plans and Medi-Medi Plans will find this service of particular value to meet State and Federal criteria for pricing. The customized fee schedule also allows Health Plans to address pharmacy complaints about MAC transparency so that they can purchase drugs more effectively.
Medicaid is auditing generic drug payments and, in many cases, crediting capitation rates for claims paid above the Medicaid MAC rates. Medicaid is also auditing claims paid with an AWP above the statutory definition of WAC*1.2. In all cases Medicaid is auditing per claim.
Additionally, Medicare is auditing for valid NDC numbers (National Drug Code) and audits for valid physician identifiers (DEA or NPI) are imminent. Medicare is also auditing claims on a per-claim basis for payments consistent with the Medicare MAC, also known as the Federal Upper Limit (FUL). Health Plans are being scored based on compliance with Medicare benefits, claims payments, etc.
The bottom-line is that audits continue to expand and cover a wider scope. Medicaid and Medicare are less likely to negotiate audit findings than third party payers. As a result, oversight and monitoring of your Medicaid and Medicare benefits requires more timely interventions, and non-compliance must be corrected faster to avoid unnecessary penalties.
“Pro Pharma assists with Medicaid and Medicare benefit compliance, as close to real time as possible; namely, at the PBM invoice payment,” said Carol Stern, RN, BSN, MBA, Chief Executive Officer of Pro Pharma. “In this manner, you can proactively manage your benefit plans, as you don’t have to wait for reports from CMS, or Medicaid and Medicare audits to find out what is wrong.”
Pro Pharma’s customized fully transparent Client Specific MAC Lists can be administered and maintained on a monthly basis as follows to include, but not be limited to:
- Medicaid Compliance and/or CMS FUL Compliance
- Adjustable Pricing Determinants (Lowest Cost, Average of Lowest 3 Costs, Average of all Generics, Median of all Generics)
- Multiple Price Sources, including: CMS, MediSpan, First Data Bank, Redbook
- Customizable Therapeutic Categories
- Flexible Generic Availability (Immediate availability, Predetermined time gap from end of patent, Minimum number of Generic Manufacturers, Decision allowance for generic, store brands, re-packagers, multisource, and/or branded generics)
- Modifiable Code Basis, including GCN, GPI, and NDC
In addition, Pro Pharma’s Accounts Payable Reconciliation Audits (Invoice Screens™) include MAC compliance with State Medicaid MAC and the federal FUL. And Pro Pharma’s Part D Workbook tracks all elements of Part D in every invoice, at every month, every quarter, and every year in this Accounts Payable Reconciliation method to ensure that clients are aware of Part D non-compliance in claim adjudication.
Pro Pharma’s MAC Analyses™ allows your organization control oversight, corrective action planning, and implementation of changes for your Medicaid and Medicare books of business. At a cost of pennies PMPM, transparency is in your hands.
About Pro Pharma Pharmaceutical Consultants, Inc.
PRO PHARMA is a multi-service, woman owned, privately held consulting firm offering a vast portfolio of services to public and private entities including self-insured employers, Taft Hartley Trusts and unions, public employers, for-profit hospitals and integrated health networks, health care insurance companies, worker's compensation insurers, small-to-medium sized HMO's, and physician groups.
As a primary service to plan sponsors for achieving below trend results, PRO PHARMA provides an integrated program of administrative process improvements, clinical quality oversight, and provider/member education.
Pro Pharma’s Consulting services are grounded in the use of data and the communication of that information to define benefit trends, drivers and other analytical indicators. PRO PHARMA markets Comprehensive Specialty Analyses™, JCode Calculator™, Invoice Screening ™, Pro Pharma Suite of Tools™, Rx MAC List™, Quality Management Program™, Treatment Calendar™, and Biotech Modeling™. The Pro Pharma directly markets its products in the U.S. and collaborates with partners to reach international markets.
About Comprehensive Specialty Analyses™
Comprehensive Specialty Analyses™ utilizes a multi-pronged approach to analyze pharmacy and medical encounter claims through problem flagging, feedback on performance, peer to peer comparison, and others parameters. Comprehensive Specialty Analyses™ specifically identify pricing differences, usage, trends, and actionable opportunities in the medical data that were not apparent in the past. In order to achieve these goals it is necessary to view the Medical Data from multiple perspectives, i.e., a 360 degree view that allows for seeing beyond the obvious of top drugs spend and top providers as well as compare and contrast it with the Pharmacy Claims Data.
About JCode Calculator™
Pro Pharma has developed a Standardized Injectable Fee Schedule to assist with the management of claims payment. The advantage to this product is that it bases all Injectable reimbursement on AWP, WAC and ASP cost, and can be customized for drug category discounts or multiple discounts based on drug type or specialty. It includes at least one AWP for every HCPS Code and CPT code description;
About Invoice Screening™
About 10% of drugs spend is being paid from PBM Invoices, and should have been rejected by clients prior to payment. Pro Pharma’s Invoice Screening™ analyzes invoices against: formulary compliance, compliance with MAC pricing, eligibility, claims pricing, invalid claims, and excluded benefits, pre-payment as an Accounts Payable function. This ensures that clients only pay for valid claims, which saves time and dollars in the long run.
Carol Stern, CEO