Summary: As senior citizens continue to learn and understand their new Medicare Part D prescription drug coverage, so do the drug plan providers who administer these benefits. The latest hurdle for prescription drug plan providers comes in the form of the new guidance and regulations recently released by the Centers for Medicare and Medicaid Services (CMS), which set forth expectations for subcontractor accountability for managed-care organizations and their pharmacy benefits managers. Brian Bullock and Rob Shelley, president and vice president of The Burchfield Group, discuss the real-world impact of the regulations in today’s installment of The Burchfield Group’s Pharmacy Benefits Podcast, downloadable for free at www.burchfieldgroup.com or in the iTunes podcast directory. The Burchfield Group is a pharmacy benefit consulting firm that helps employers and plan providers manage the prescription drug benefits they offer. “As the government is giving money to the private sector, it insists on verifying the integrity of the administration and operation of subcontractors to the health plan,” Bullock said. “They want to ensure that the pharmacy benefit managers are administering the benefits honestly, accurately and efficiently. A PBM that administers a pharmacy benefit on behalf of a managed-care organization is expected to be held accountable as if it were a department within the managed-care organization.” CMS has submitted 12 new draft requirements to provide oversight of Medicare Part D and prescription drug programs, seven of which relate directly to the role of subcontractors in health care plans. Topics of the draft requirements include medication therapy management; fraud, waste and abuse; drug utilization management process; and contract and maintenance of records, among others. Violations of these guidelines, which can multiply quickly and dramatically if they go unnoticed or uncorrected, can cripple a managed-care organization and drag its reputation through the mud. In order to comply with the new regulations, Shelley emphasized that the first steps are to perform an audit of existing processes and examine all contracts thoroughly. “Existing contracts may not address all the aspects now subject to higher regulation,” Shelley said. “Plan providers cannot simply rely on PBMs providing oversight when the plan provider is ultimately held responsible for violations and its own integrity.” According to Bullock, CMS is essentially using these new regulations to have companies establish a “best effort” in terms of compliance. “It’s likely that the government will be looking to make an example of companies who do not make a best effort to meet the new requirements,” Bullock said. “Ultimately, subcontractor accountability is all about auditing the relationship between yourself and the PBM that is administering the program for you.” Bullock invites his podcast listeners to submit questions and comments, which he and Shelley will address in future podcasts. Send an e-mail to bbullock@burchfieldgroup.com or call 651-389-5640 with questions or to learn more about making the right Medicare Part D decisions.
