Pbms Tools

[Earlie Schwoyer]

Withongoing challenges such as the COVID-19 pandemic, rising healthcare costs, and changing regulatory requirements, healthcare organizations face increasing pressure to ensure efficient resolution of member grievances while maintaining compliance with industry standards.

Navigating the Impact of COVID-19: The COVID-19 pandemic has placed unprecedented strain on healthcare systems worldwide. With an influx of inquiries, complaints, and concerns from members, healthcare organizations must have robust mechanisms to manage grievances effectively. GrievancesHub offers a centralized platform for tracking and resolving member complaints, ensuring timely responses and improved member satisfaction, even amidst challenging circumstances.

Meeting Regulatory Requirements: Regulatory compliance remains a top priority for healthcare organizations. GrievancesHub is designed to satisfy the stringent requirements of the Centers for Medicare & Medicaid Services (CMS) and other regulatory bodies. From customizable turnaround times to robust reporting capabilities, GrievancesHub equips organizations with the tools to maintain compliance and uphold industry standards.

Enhancing Member Experience: In an era where patient-centric care is paramount, delivering an exceptional member experience is essential. GrievancesHub facilitates seamless communication and resolution, fostering positive interactions between members and healthcare organizations. Organizations can cultivate trust and loyalty among their member base by providing timely responses and personalized support.

Optimizing Operational Efficiency: As health plans and PBMs strive to do more with less, optimizing operational efficiency is crucial. GrievancesHub streamlines the grievances management process, reducing manual tasks and administrative burdens. With features such as role-based access, intelligent automation, and enhanced workflow, GrievancesHub empowers organizations to maximize productivity and minimize resource allocation.

In conclusion, GrievancesHub represents a cornerstone in the efforts of health plans and PBMs to navigate the complexities of grievance management. As organizations face unprecedented challenges and opportunities, GrievancesHub stands ready to support its mission of delivering high-quality care, enhancing member satisfaction, and ensuring compliance with regulatory requirements.

For Health Plans, PBMs, and TPAs, formulary management stands as a critical pillar in ensuring optimal patient care while managing costs effectively. As complexities surrounding formularies continue to mount, traditional approaches lack efficiency and are proving...

The recent final rule for the 2025 contract year issued by the Centers for Medicare & Medicaid Services (CMS) carries significant implications for Health Plans and Pharmacy Benefit Managers (PBMs) managing Medication Therapy Management (MTM) programs. This change...

As our industry continues to evolve, efficiency, security, and adaptability are non-negotiables. Health plans, Pharmacy Benefit Managers (PBMs), and Third-Party Administrators (TPAs) need robust solutions that not only streamline operations but also ensure compliance,...

The need for effective Prior Authorization (PA) management for health plans, Pharmacy Benefit Managers (PBMs), and Third-Party Administrators (TPAs) continues to evolve. To propel your organization to new heights, it's not just about managing authorizations but...

Planning for the Future of Healthcare Legislation: Agadia's Response to Colorado Revised Statutes When it comes to healthcare legislation, staying ahead is not just a necessity; it's our commitment at Agadia. As of February 20, 2024, the Colorado Revised Statutes...

In response to escalating concerns voiced by providers and patients regarding delayed and denied care, an increasing number of states are taking decisive steps to impose limitations on prior authorization (PA) requirements. These legislative efforts, reaching beyond...

The healthcare landscape is undergoing a transformative shift with the introduction of the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F). This comprehensive regulation sets forth a series of...

The Biden-Harris Administration's recent announcement on promoting competition in healthcare includes a significant focus on increasing transparency in the Medicare Advantage (MA) insurance market. The U.S. Department of Health and Human Services (HHS) and the Centers...

Most state Medicaid programs maintain a preferred drug list (PDL) of outpatient prescription drugs, which is a list of outpatient drugs states encourage providers to prescribe over others. At least 45 states use PDLs in their fee-for-service (FFS) drug programs.3,4 A state may require prior authorization for a drug not on a preferred drug list or attach a higher co-pay, creating incentives for a provider to prescribe a drug on the PDL when possible. Since states are required to make available nearly all prescribed drugs from manufacturers with a national rebate agreement in both managed care and fee-for-service settings, PDLs allow states to manage utilization. In addition, PDLs often include drugs which are lower-cost or for which a manufacturer has provided supplemental rebates, as PDL placement is a primary lever that states use to negotiate supplemental rebate agreements.

States are required by federal law to have a drug utilization review (DUR) program in place to help ensure appropriate drug use.10 Drug utilization review programs must establish standards to ensure prescriptions are appropriate, medically necessary, and unlikely to lead to adverse medical results. DUR programs must also include evaluation for problems like duplicate prescriptions, incorrect dosage, and clinical misuse.11

DUR is a two-step process conducted by state Medicaid agencies, consisting of both prospective and retrospective drug utilization review. In prospective DUR, state Medicaid agencies employ electronic monitoring systems to screen prescription drug claims for concerns like duplicate prescriptions, incorrect dosage or duration of treatment, contraindications, and clinical misuse or abuse. Retrospective DUR is ongoing and involves periodic examination of claims data to identify patterns of fraud, abuse, underutilization, and medically unnecessary care.12 States are required to establish a DUR board to create the standards for appropriate drug use and to conduct retrospective drug utilization review. The board membership must consist of at least two-thirds physicians and pharmacists.13

Federal law requires states to make an annual DUR report on their Medicaid prescribing patterns, cost-savings associated with DUR, board activities and program operations. According to CMS, states saved an average of $57 million in 2017 through prospective DUR, and $1.46 million through retrospective review.14 However, due to heterogeneity in the methodologies used by states to calculate savings, comparisons of program cost-savings between states are unreliable.15

States have the authority to implement cost-sharing to control utilization and costs of prescription drugs. For example, states may implement different co-payments for drugs on a preferred drug list or generic drugs, compared to non-preferred or brand drugs. Most states now utilize some measure of cost-sharing in their Medicaid pharmacy benefit. In fiscal year (FY) 2018, 35 states and DC reported having co-payments for prescription drugs in place for Medicaid non-exempt beneficiaries.21 Co-payments are statutorily capped at $4 for preferred drugs. For non-preferred drugs, states may require co-pays up to $8 for most beneficiaries with income at or below 150% of the federal poverty level (FPL).22

In addition to implementing cost-sharing, states may limit the number of prescriptions a beneficiary may access without prior authorization. These restrictions may include a limit on the total number of prescriptions per month or a limit on the number of brand drugs. Medicaid programs allow prescribers and pharmacists to submit prior authorization requests to override these limits when medically necessary or under other specific circumstances, subject to federal requirements for prior authorization processes. In addition, states are authorized under federal law to set minimum or maximum numbers of pills or doses per prescription as well as the number of refills.23 In order to implement prescription coverage restrictions that are not expressly permitted by federal statute,24 states need waiver authority from CMS. For example, Tennessee implemented a prescription coverage limit of five prescriptions per month for adult beneficiaries not in long-term care in its TennCare demonstration.25 However, the state exempts many medications from the prescription limit and allows prescribers to submit exception requests for beneficiaries.26

States continue to use pharmacy utilization management strategies in Medicaid, but because most states have adopted most of these strategies, activity is generally around refining them. However, such actions have slowed in recent years as states reach the limits of utilization controls allowed under federal law. The rise in prevalence of managed care in Medicaid and in pharmacy benefits has also led to changes in how states manage their benefits.

Capitated managed care is now the dominant way in which states deliver services, including prescription drugs, to Medicaid beneficiaries. States pay managed care organizations (MCOs) a monthly fee (capitation rate) to cover the cost of services provided to beneficiaries and any administrative expenses. Thirty-three of the 40 states with comprehensive risk-based managed care enroll at least 75% of their Medicaid beneficiaries in MCOs.27 As more states have enrolled additional Medicaid populations into managed care arrangements over time and included pharmacy benefits in managed care contracts, MCOs have played an increasingly significant role in administering the Medicaid pharmacy benefit. Although MCOs provide comprehensive services to beneficiaries, states may carve specific benefits, including the pharmacy benefit, out of MCO contracts to FFS systems.

3a8082e126