MPhA Successful in Passing Audit Integrity Act!
HF 1236/SF 973 (the Pharmacy Audit Integrity Program), passed both the Minnesota House of Representatives and the Senate by unanimous vote this session. These bills are the result of numerous meetings between the MPhA staff and community pharmacists and Pharmacy Benefit Manager (PBM) industries over the past year, ultimately reaching compromise with both industries approving the final language. The bill establishes reasonable guidelines for how PBMs conduct their audits on pharmacy claims without inhibiting the PBM’s ability to uncover fraud, waste and abuse. Key elements of the bill include:
- Requires PBMs to notify pharmacies any time the terms of a contract are changed.
- Requires PBMs to give pharmacies advance notice of an audit so that the pharmacy can have appropriate records and staff available to assist in the audit.
- Sets reasonable limits on how far back an audit can look and the number of claims that may be audited.
- Prevents audits from being performed during very busy times in the pharmacy and sets guidelines for how auditors should conduct themselves in the pharmacy.
- PBMs may not require pharmacies to record information on the face of a prescription that is not already required by State or Federal regulation.
Compensation for auditors may not be based on the amount they recoup in an audit.
- PBMs may not recoup money in an audit unless pharmacy error caused monetary harm to the patient or plan or the pharmacy has failed to comply with a corrective action plan.
- Pharmacies may use records or statements of a physician or health care facility to validate or substantiate a prescription claim.
- PBMs must establish a written appeals process for results of an audit.
The above guidelines do not apply in audits that involve suspected fraud, willful misrepresentation or abuse.
This legislation represents a carefully negotiated compromise between the two affected industries, and both groups agreed to the language. The bill was and was signed by Governor Dayton on April 23. The complete language may be viewed at www.mpha.org.
back to top
Update your Academy Listing with MPhA!
MPhA recognizes the diverse areas of practice in Minnesota. Academies allow members in the same practice setting to interact and discuss issues important to their field. MPhA is creating listservs for each Academy to help members better communicate with members.
We ask that each member update their profile to indicate which Academies you would like to subscribe OR not subscribe to.
Please log into your MPhA Profile, click View/Edit Profile and scroll to see your Academy Listerv preferences. If you are currently subscribed to an Academy Listing and you would like to opt out of the listserv, please update your preference to NONE.
back to top
CMS Memorandum to Part D Sponsors
Cynthia G. Tudor, Ph.D., Director, Medicare Drug Benefit and C & D Data Group, has issued this reminder regarding prescription transfer requirements.
CMS has recently observed an increase in beneficiary complaints related to the transfer of prescriptions from retail pharmacies to either mail-order or specialty pharmacy without their explicit consent. The purpose of this memorandum is to remind Part D sponsors of the requirements related to the transfer of prescriptions. Specifically:
- Any prescription transfer from one pharmacy to another, initiated by the plan, would require release of the model notice and permission by the beneficiary.
- The model notice should only be used when the transfer of the prescription is not initiated by the beneficiary (or someone on their behalf).
- The beneficiary can initiate the request by contacting the plan or pharmacy or can mail/fax the permission form to the plan.
- Unsolicited phone calls made by the plan or pharmacy seeking permission from beneficiaries to transfer a prescription are not permitted.
The original guidance to this policy can be found in the 2010 Call Letter and revised in a HPMS memorandum issued on January 12, 2010 (“Revisions to Model Part D Prescription Transfer Letter (previously titled Model Part D Mail-Order Letter) for CY 2012”). The 2012 Model Prescription Transfer Letter can be found at www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Part-D-Marketing-Model-Materials.html.
The use of other mechanisms, such as Prior Authorization forms, to steer a beneficiary into a mail-order pharmacy is against CMS requirements and should be discontinued immediately. The choice of which network pharmacy to use is at the sole discretion and convenience of the beneficiary. If you have any questions related to this policy or memorandum, please contact your CMS account manager.
back to top
MPhA Offers MTM Certification Training July 27, 2012
MPhA will offer MTM Certificate Training in St. Paul at the association offices on Friday July 27, 2012. This certificate training is the APhA MTM Training with the twelve patient case required for completion per Minnesota Medicaid requirements. This all day training is offered to members at $595 and non-members at $695. Registration will be available at mpha.org beginning May 15.
back to top
2012 Summer Institute: The Times, They are a Changin’
June 12, 2012 | Earle Brown Heritage Center in Brooklyn Center
This day-long meeting, co-sponsored with the Department of Human Services, MN Board on Aging, and the Leadership Council on Aging, will be an opportunity to inspire productive change. Though out the day we will review a number of initiatives in Minnesota including the health care home, advanced care planning, reducing avoidable hospital readmissions, integrated care for dually eligible adults, Medicare Accountable Care Organizations, Medical Assistance reform, and transitional care. Most of the day will be spent in small group breakout sessions that encourage participants to actively discuss each topic.
Lucinda Jesson, Commissioner at DHS, and former Senator Dave Durenberger are offering remarks in plenary sessions. Cathy Wurzer of MPR will round out the afternoon, moderating a panel of consumers, geriatrician Ericka Tung, MD of Mayo, and a couple legislators.
REGISTER TODAY: www.coa.umn.edu
Click on the Summer Institute link
$125 ($50/Seniors & Students)
back to top