Best Practices. How to Approach the State for Medicaid Dispute Resolution

Transcription

1 Best Practices How to Approach the State for Medicaid Dispute Resolution

2 Panel Participants Manufacturer Representative: Michael Fraclose Analyst, Government Contracts, Cephalon Inc. State Representatives: Carrie Gray, MBA Pharmacy Program/Policy Analyst, WI Medicaid Cindy LaClair KS Drug Rebate Specialist, EDS, an HP company Katherine Landry, MBA Drug Rebate Manager, Unisys Florida Medicaid Moderator: Daniel Bustamante Training and Marketing Support, Data Niche, A unit of IMS Health

3 Overview Knowledge of Drug Product State Laws State Regulations/Limitations Recent CMS Mandates External Factors to Consider 340b Communication

4 Knowledge of Drug Product Conditions Sold Distribution Discounts Shifts in PDL Status Indications Illnesses Diagnosis Dispensing Unit of Measure Unit Per Package Size NDC/HCPCS Crosswalk Inner vs.outer NDC (11 digit NDC) UPC vs. NDC

5 Conditions Claims Level Detail State laws If requested, can State send? Available through OutlierView system Generic substitutions SMAC pricing -Some states provide online FUL pricing Prescription documents Length of time kept

6 State Regulations/Limits Archives of PDL and SMAC Dispensing Fees Edits and Audits on claims Units too high or low Days supply comparison to units dispensed Non Medicaid Reimbursements What does that include? - Third Party Payments, Medicare, Patient Liability, Copay for all claim types Claim Exclusions PHS (340b), non rebate eligible drugs, zero pd claims Benefit vs. Cost Threshold Invoiced total threshold Reimbursed amount threshold if URA is zero

7 Recent CMS Mandates Manufacturers and States DRA Invoicing Multi Source HCPCS top 20 or all Invoice changes - Non Medicaid Reimbursement CMS Releases - Updating drug files non rebate eligible & DESI Manufacturer Rebate Per Unit credits - Rate changes going back to 1991

8 External Factors to Consider Manufacturers and States Staff How many in Drug Rebate area? What type of background? - Manufacturers have 50 States, Supplemental and SPAP contracts - States have 500+ potential Manufacturers Expansions and Additional Programs -SPAP Length of time in Drug Rebate? - New will need more time to research and resolve - No replacement at this time Current Economy States can t afford to go to conferences - Put at bottom of dispute resolution list State Medicaid Programs in dire straits - More people becoming eligible - Less money flowing back in due to recent RPU credit changes

9 Precision of HRSA States and 340b 340b Overview How does a state decide to exclude claims from rebate invoice? Historic 340b resolution tips OutlierView Pharmacy Filters

10 Precision of HRSA Site - HRSA Site reports what the provider indicates currently no validation that the NPI/Provider ID is correctly listed as excluded - Medicaid Exclusion Tutorial -

11 States and 340b Providers knowledge of 340b runs a broad spectrum Know your States Find out how States are excluding claims from invoice Claim level or provider level Strictly from HRSA site and/or do they do their own validation? Some states have an indicator on the provider file and/or give an enhanced dispensing fee

12 How Does a State Exclude Items from Rebate Invoice? Are passing the discount onto Medicaid? Calculate % paid of Medicaid allowed for each provider each quarter and store data historically If Provider ID/NPI is listed with HRSA AND the provider is billing Medicaid well under the non-340b average we exclude the provider s claims If the Provider ID/NPI is listed with HRSA but the provider is not passing on the discount, we call them and find out if they are dispensing 340b stock to their Medicaid recipients

13 Historic 340b Resolution Tips Search HRSA site for entities at the provider s address do they have Med No listed? Review how provider is billing over time Utilize state s MPI office Call the providers in question and log the calls HRSA has 340b contact on their site Ask manufacturer for chargeback data The manufacturer should have chargeback invoices from the wholesaler tied to the provider s address whose claims they are disputing

14 OutlierView: PHS Matched

15 OutlierView: My Pharmacy List

16 Communication States avoiding unnecessary disputes Verification Validation State Supplemental Invoices: having components available to calculate rate, WAC, etc. States working together

17 Communication Manufacturers and CMS Review DDR All data is correct and up to date -States do not currently have access, according to CMS it will be in future Review Rebate Per Unit Some rates sent to CMS are changed prior to sending to States -KS submits a PPA invoice every quarter showing these changes as a FYI only invoice. Compare State Invoice to OutlierView data

18 OutlierView Invoice/Data Comparison

19 Communication Manufacturers and States Send States CMS mandated detail for disputed NDCs with ROSI: Package size dispcrepancies (F) Transferred NDC (G) J-code to NDC crosswalk (K) Discontinued/term NDC (N) States units invoiced exceed sales (P) Utilization/Qty inconsistent w/reimb levels (R) Utilization/Qty inconsistent w/state trends (S) Utilzation/Qty inconsistent w/lowest dispensable pkg size (T) Product not rebate eligible (U) No record sales to state or state history (V) PHS entity not extracted (X)

20 OutlierView Rx-Level Detail Rx Data Fields NDC code Medicaid Pharmacy ID/NPI* Rx ID Internal Control Number Refill Code Paid Date Service Date Units Dispensed State Reimbursement Third Party Liability Amount Billed Co-Payment Dispensing Fee Source Code Days Supplied Description National Drug Code identifying the product dispensed Dispensing Pharmacy Medicaid Identification Number/NPI *Additional Medicaid Pharmacy Information: Pharmacy Medicaid ID, Street Address, City, State, Zip Script Identification Number Internal Script Identification Number used for the tracking of a script across quarters Code indicating if the script is the original or a refill of a previous script Date the State paid the pharmacy for the prescription Fill date of the prescription as reported by the pharmacy Number of units dispensed by the pharmacy State portion of payment + Dispensing Fee Any additional third-party payment applied to the cost of the prescription Dollar amount billed to the state for the prescription (Prescription Cost + Dispensing Fee) Dollar Amount Paid by Patient Dollar Amount Paid to the Pharmacist by the state for dispensing the Rx Identifies claims that have been cross-walked from a J-Code to an NDC The number of days that the Rx should last.

21 Communication Manufacturers and States Send States CMS mandated detail for disputed NDCs with ROSI Paragraph explanation Detail data (OutlierView) showing Rx information Hand-written on the ROSI List Opportunities for Dispute Resolution Data Niche Conference

22 Communication Manufacturers and States Work closely with State dispute contacts Educate -Not all State contacts have pharmacy background -New staff Set reasonable timeline for resolution -Stay within State Laws for requesting documents for disputes -CMS guidelines indicates that good faith negotiations between manufacturer and state should be completed within 240 days or 4 months after receipt of dispute from drug manufacturer. Willingness to agree on a resolution -Both parties should be in agreement and allow some give and take on both sides if questionable claims still exist and cannot be proved either way

23 CMMView: Communications Management

24 Summary Knowledge of Drug Products Knowledge of Pertinent Legislation/Mandates 340b Ongoing Communication

25 Questions?

26 Thank You and Have a Magical Day!