Audits of healthcare providers are inevitable. Negative findings and allegations of overpayment are almost certain too. Because of voluminous records to be reviewed and scrutinized, auditors use extrapolation, reviewing only a snippet of all claims submitted. If any of the claims reviewed do not comply with applicable regulations and generally accepted practices – or contain
Recently, media, pharmacy groups, and policy makers have been focusing on so-called “gag clauses” in PBM contracts, which prevent pharmacies from discussing cheaper payment alternatives with their patients. Watch NBC’s coverage here.
So what exactly is a gag clause? As applicable to pharmacy, a gag-clause is a provision in a PBM contract that prohibits
Last week, Express Scripts – a pharmacy benefit manager (PBM) – announced that it has reached an agreement to acquire eviCore – a medical benefit manager (MBM) – for $3.6 billion. eviCore manages medical benefits for 100 million people in areas of radiology, cardiology, musculoskeletal disorders, post-acute care and medical oncology. Express Scripts is the
Oregon became another state to further increase its oversight over PBMs. Oregon has required PBM registration since 2013, however, it had no actual oversight over PBMs operating in the state. The new law – coming in effect on January 1, 2018 – grants Oregon Department of Consumer Services (DCS) the authority to deny, revoke, or
I’ve come across a very informative article written by William McConnell, “Behind the War Between HealthPlans and PBMs” that I want to share with you today. Click here to access the article.
Interestingly, the author predicts that despite the new administration’s pledge to reduce drug cost and spending, it’s unrealistic to expect that anything will
The bill would require PBMs to be licensed by the California State Board of Pharmacy and provides for greater transparency in PBMs’ dealings with health plans. The proponents of the bill argue that by allowing the Board to regulate PBMs would provide pharmacies with redress when wronged by aggressive PBM practices. In addition, the bill
Recently, Sen. Wyden has introduced a bill, tilted “Creating Transparency to Have Drug Rebates Unlocked (C-THRU) Act.” The purpose of the bill is to require PBMs to share more information about the rebates they receive and how much of the rebates they actually pass to the plans.
The terms of the contracts between PBMs and
A little background on the case: In 2015, three compounding pharmacies brought a case against four largest PBMs—Express Scripts, CVS Health Corporation, OptumRx, Inc., and Prime Therapeutics, LLC—under the Employee Retirement Income Security Act (ERISA), alleging that PBMs systematically denied payment of compound drug claims without adhering to ERISA’s claims regulation. The judge denied pharmacies’
During the last two years, we’ve seen a sweep of MAC transparency laws across the nation. The intent of these laws is to provide pharmacies with a look into how PBMs determine generic drug reimbursement. When entering into a PBM contract, many independent pharmacies do not receive a clear definition of Maximum Allowable Cost (MAC)
Happy 2017 to all of you working with PBMs! You made it through a tough 2016. By that I mean:
Increased PBM transparency
Constant pressure on lowering cost
Shorter-term contracts
Change in specialty drugs delivery and reimbursement models
Lower pharmacy reimbursements
In 2016, prescription drug prices rose an average of 7% (the largest increase in