BUILDING THE PBM/VENDOR RELATIONSHIP

Transcription

1 Aaron Musgrove-Lecours Director, Pharmacy Operations FDR Oversight: How Do You Do it (or Not)? 2015 Compliance Institute April 19, 2015 BUILDING THE PBM/VENDOR RELATIONSHIP 1. The right thing is good for vendor, plan and members 2. Educate on your membership 3. Integration Engage your vendor in quality Get them to appreciate the connection to customer satisfaction and business growth 4. Common Goals 1

2 BUILDING THE PBM/VENDOR RELATIONSHIP 1. The right thing is good for vendor, plan and members 2. Educate on your membership 3. Integration 4. Common Goals Share your organization s story, have PBM share it with staff handling your account Visit call centers, prior authorization centers Speak with employees directly Educate on your membershipdemographics, challenges, etc. BUILDING THE PBM/VENDOR RELATIONSHIP 1. The right thing is good for vendor, plan and members 2. Educate on your membership 3. Integration 4. Common Goals PBM staff- extension of your organization Should share responsibility for your membership 2

3 BUILDING THE PBM/VENDOR RELATIONSHIP 1. The right thing is good for vendor, plan and members 2. Educate on your membership 3. Integration 4. Common Goals Establish and emphasize shared goals If organization s membership is happy and PBM performs well, plan will likely grow, increasing revenue for vendor and plan YOUR ACCOUNT TEAM BUILD THE RELATIONSHIP MANAGE AS ONE OF YOUR OWN 3

4 MANAGE AS ONE OF YOUR OWN 1. Weekly calls 2. Quarterly onsite visits 3. Clear expectations Operations Clinical Medicare 4. Don t abuse 5. Encourage proactive, collaborative relationship MANAGE AS ONE OF YOUR OWN 1. Weekly calls 2. Quarterly onsite visits 3. Clear expectations 4. Don t abuse 5. Encourage proactive, collaborative relationship Tour site and make note of operations Interview operational staff familiar with your account Review training programs Meet with management Provide information about your organization 4

5 MANAGE AS ONE OF YOUR OWN 1. Weekly calls 2. Quarterly onsite visits 3. Clear expectations 4. Don t abuse 5. Encourage proactive, collaborative relationship How quickly do you expect a response? Must some responses be handled faster than others? and return call expectations Establish who should be making requests of account team Check-in on workload: opportunities for more self-sufficiency? MANAGE AS ONE OF YOUR OWN 1. Weekly calls 2. Quarterly onsite visits 3. Clear expectations 4. Don t abuse 5. Encourage proactive, collaborative relationship Catch more with honey Limit wasteful, time consuming requests Utilize client tools Frees team to handle requests you can t do yourself Automated report delivery Limit ad hoc report requests Set up subscriptions for special report requests Reports can take a lot of time from your account team s day, cutting into time to address other issues 5

6 MANAGE AS ONE OF YOUR OWN 1. Weekly calls 2. Quarterly onsite visits 3. Clear expectations 4. Don t abuse 5. Encourage proactive, collaborative relationship Frequent engagement with account team Set clear goals Solicit input from account team to help achieve these goals Set tone of transparency Shared risk from a business perspective Collaboration is key Large PBM often has more resources to leverage and this benefits both parties Philanthropic opportunities DO YOU SEE WHAT I SEE? 6

7 1. Call Centers 2. Prior Authorizations Listen to calls Have PBM inform their staff you are listening to calls 3. Reject and Paid Claims Review 4. Site Visits 5. Formulary Administration and Pricing Monitor metrics Set expectations for call center metrics across all lines of business Medicare is good benchmark 1. Call Centers 2. Prior Authorizations Letter Review Decision Review 3. Reject and Paid Claims Review Turn-around times 4. Site Visits 5. Formulary Administration and Pricing 7

8 1. Call Centers 2. Prior Authorizations 3. Reject and Paid Claims Review 4. Site Visits 5. Formulary Administration and Pricing Reject claim review daily for Medicare Protected class follow-through Reject and Paid claim review weekly for other lines of business Reject review for oversight of formulary administration Paid claim review for oversight of formulary administration Coding errors= recoverable dollars 1. Call Centers 2. Prior Authorizations Call Centers PA Centers 3. Reject and Paid Claims Review 4. Site Visits Specialty Mail Order 5. Formulary Administration and Pricing 8

9 1. Call Centers 2. Prior Authorizations Formulary Updates on website Submission of formulary to State and CMS 3. Reject and Paid Claims Review 4. Site Visits Audit of pricing and formulary Coding errors and pricing errors frequent with PBMs 5. Formulary Administration and Pricing 6. Fraud, Waste and Abuse Establish relationship between SIU and PBM s FWA unit, keep compliance officer 7. Financials 8. Clinical Programs involved Ride along on pharmacy audits Refer cases and maintain communication 9. Pharmacy Network/ other subcontracting 10.Policy and Procedures 9

10 6. Fraud, Waste and Abuse 7. Financials 8. Clinical Programs Prior Auth. Billing Clinical Programs Billing Invoice- Claims and Admin Billing 9. Pharmacy Network/ other subcontracting 10.Policy and Procedures 6. Fraud, Waste and Abuse 7. Financials 8. Clinical Programs Meeting clinical objectives Meeting ROI s Recovery for guaranteed ROI s not met 9. Pharmacy Network/ other subcontracting 10.Policy and Procedures 10

11 6. Fraud, Waste and Abuse 7. Financials 8. Clinical Programs Attestation of compliance for downstream entities Attestation of credentialing and recredentialing 9. Pharmacy Network/ other subcontracting 10.Policy and Procedures 6. Fraud, Waste and Abuse 7. Financials 8. Clinical Programs Track and collect Review Yearly Updates based on Medicare Call letter 9. Pharmacy Network/ other subcontracting 10.Policy and Procedures 11

12 TRACKING YOUR SUCCESS AM I GETTING ANYWHERE? 1. Monitoring TRACKING YOUR SUCCESS Daily 2. Document Everything 3. Stay Organized 4. Trends 5. Internal Audits Weekly Monthly Quarterly Annually 12

13 1. Monitoring TRACKING YOUR SUCCESS CAPS 2. Document Everything 3. Stay Organized Oversight Reporting 4. Trends 5. Internal Audits 1. Monitoring TRACKING YOUR SUCCESS Shared Folders 2. Document Everything 3. Stay Organized 4. Trends Central Location for all documents Set a naming convention Separate lines of business 5. Internal Audits 13

14 1. Monitoring TRACKING YOUR SUCCESS Areas with recurring issues 2. Document Everything 3. Stay Organized Areas with no issues Eliminate or reduce oversight 4. Trends 5. Internal Audits 1. Monitoring TRACKING YOUR SUCCESS Is your program working? 2. Document Everything 3. Stay Organized 4. Trends 5. Internal Audits Can you provide information to regulatory entities efficiently? Surveying your membership Specialty Benefit Call Center effectiveness 14