May 2014 Manufacturer Webinar Angela Stanley, CMS, Division of - - PowerPoint PPT Presentation

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may 2014 manufacturer webinar angela stanley cms division
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May 2014 Manufacturer Webinar Angela Stanley, CMS, Division of - - PowerPoint PPT Presentation

Jul 26, 2023 463 likes •917 views

May 2014 Manufacturer Webinar Angela Stanley, CMS, Division of Payment Reconciliation Agenda CGDP Data Overview CGDP Appeals Website and Portal Improvements An EFT Reminder Live Q&A 2 CGDP Data Overview Amanda Johnson,

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May 2014 Manufacturer Webinar

Angela Stanley, CMS, Division of Payment Reconciliation

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  • CGDP Data Overview
  • CGDP Appeals
  • Website and Portal Improvements
  • An EFT Reminder
  • Live Q&A

Agenda

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CGDP Data Overview

Amanda Johnson, Director, Division of Payment Reconciliation

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Discount Eligible Beneficiary Distribution

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5,000,000 10,000,000 15,000,000 20,000,000 25,000,000 30,000,000 35,000,000 40,000,000 2011 2012 2013 2014

LICS vs Non LICS Benes Across Benefit Years

Non-LICS Bene Count LICS Bene Count

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Discount Eligible Beneficiaries in Defined Standard Plans

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  • 500,000

1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 2011 2012 2013 2014

Defined Standard Benefit Plan - LICS vs Non LICS Beneficiary Trend by Benefit Year

Non-LICS Bene Count LICS Bene Count

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Discount Eligible Beneficiaries in Enhanced Alternative Plans

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  • 2,000,000

4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 14,000,000 16,000,000 18,000,000 2011 2012 2013 2014

Enhanced Alternative Plan -LICS vs Non LICS Beneficiary Trend by Benefit Year

Non-LICS Bene Count LICS Bene Count

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Discount Eligible Beneficiaries in Employer Group Waiver Plans

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  • 1,000,000

2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 7,000,000 2011 2012 2013 2014

EGWP -LICS vs Non LICS Beneficiary Trend by Benefit Year

Non-LICS Bene Count LICS Bene Count

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Quarter Beneficiaries Enter the Gap

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6.6% 8.6% 9.1% 24.6% 26.8% 26.2% 36.7% 35.0% 35.6% 32.1% 29.6% 29.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2011 2012 2013 Q4 Q3 Q2 Q1

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Discount Eligible Beneficiaries by Benefit Phase, Program-wide

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3,251,770 3,267,691 3,945,108 468,839 494,864 661,850 5,000,000 10,000,000 15,000,000 20,000,000 25,000,000 2011 2012 2013 Catastrophic Coverage Coverage Gap Initial Coverage Period Deductible Coverage

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2013 Ending Benefit Phase for EGWP Discount Eligible Beneficiaries

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3% 69% 25% 3%

2013 EGWP

Deductible ICP Gap Catastrophic

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2013 Ending Benefit Phase for EA Discount Eligible Beneficiaries

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0% 83% 14% 3%

2013 Enhanced Alternative Plan

Deductible ICP Gap Catastrophic

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2013 Ending Benefit Phase for All Other Plan Types Discount Eligible Beneficiaries

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23% 61% 13% 3%

2013 All Other Plan Types

Deductible ICP Gap Catastrophic

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Average Gap Discount Amount 2011 $ 603.75 2012 $ 705.56 2013 $ 910.69

Average Gap Discount Amount per Beneficiary

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Coverage Gap Discount Program (CGDP) Appeals

Independent Review Entity (IRE) for the Centers for Medicare and Medicaid Services (CMS)

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Independent Review Entity for CGDP

Review appeals of denied disputes

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CGDP Appeals

  • Affirm the appeal

– (disagree with denial)

  • Deny the appeal

– (agree with denial)

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File TPA Dispute Correctly

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Know the Guidance

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  • Not calculated correctly
  • Not calculated with accurate data
  • Explain why determination is incorrect
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Reason Codes

  • Duplicate Invoice Item
  • Closed Pharmacy
  • Not a Covered Part D Drug

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Reason Codes

  • Aberrant Quantity
  • High Price of the Drug
  • Last Lot Expiration

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Reason Codes

  • Marketing Category

– Not NDA – Not BLA

  • Excessive Gap Discount

– Single – Cumulative

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Excessive Gap Discount Single Claim

2013 – TrOOP is $4,750 and the plan covers 2.5% of negotiated drug costs [($4,750÷0.975) X 0.50] 2014 – TrOOP is $4,550 2013 – Maximum discount $2,435.90 2014 – Maximum discount $2,333.33

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Excessive Gap Discount Cumulative Claims

Depends on secondary payers and their TrOOP status

2013 - maximum discount for multiple claims is $4,750 2014 - decreases to $4,550

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Appeals Received

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Appeals by Reason Codes

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Appeal Outcomes

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DRN Outcomes

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Affirmed Examples

  • Part D Sponsor stated the PDEs would

be adjusted

– Incorrect calculation – Incorrect NDC – Incorrect quantity – Incorrect data submitted

  • Exceeded maximum discount
  • Not Part D Covered Drug

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Denied Examples

  • Supporting evidence absent

– Non covered drugs – Excessive gap discount – Inappropriate doses – Excessive cost

  • Prior Authorization present

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Conclusion

  • File your dispute correctly
  • File your appeal timely
  • Respond to communications received

from the IRE

CGDPAppeals@provider-resources.com

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CGDPAppeals@ provider-resources.com

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Website and Portal Improvements

Art Spaziano, Manager Palmetto GBA Medicare Part D, CGDP TPA

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  • TPAdministrator.com

– FAQ – ListServ Announcement History

  • Manufacturer’s Portal

– Payment Confirmation

  • Support for negative amounts

– Detail reports – Confirmation responses

  • Sponsor Mailboxes

– Web based payment confirmation

Website and Portal Improvements

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TPAdministrator.com FAQ

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TPAdministrator.com FAQ

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TPAdministrator.com ListServ Announcement History

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Manufacturer’s Portal Bi-directional Pymt Confirmation

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Manufacturer’s Portal Detail Reports

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Manufacturer’s Portal Confirmation Responses

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EFT Reminder

Art Spaziano, Manager Palmetto GBA Medicare Part D, CGDP TPA

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  • It’s the only way you can receive what you’re owed
  • No Dependency on APPS system
  • Opportunity to update each quarter
  • No update needed if there are no changes
  • Reminders will be sent prior to each update deadline
  • Full set of EFT records redistributed each quarter
  • Important for Manufacturers & Sponsors to download

their respective files each quarter

  • Granular description of changes issued with each

update

  • EFT info for some DMs still missing!

EFT Information for Manufacturers and Sponsors

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Contact Information

Art Spaziano, Manager Palmetto GBA Medicare Part D, CGDP TPA

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Contacting the TPA

  • TPA website - http://tpadministrator.com
  • Phone

– Help Line: 1-877-534-2772 – Option 1 – Hours: Monday thru Friday 8am to 7pm ET

  • General email inquiries regarding the invoicing and payment process

should be sent to tpaoperations@tpadministrator.com

  • Webinar slides will be posted to the TPA website
  • Suggestions for future webinar topics should be sent to

webinar@tpadministrator.com

  • Questions related to dispute files, EFT information, invoice

corrections http://tpadministrator.com – Website

  • disputes@tpadministrator.com - Dispute support documentation

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Resources

  • Medicare Drug Benefit Group
  • Questions related to the Manufacturers Agreement, changes of ownership,

terminations, compliance / administrative-related issues, policy

  • Email address is CGDPandManufacturers@cms.hhs.gov
  • Discount Program Manufacturer’s Page
  • http://www.cms.gov/Medicare/Prescription-Drug-

Coverage/PrescriptionDrugCovGenIn/index.html?redirect=/PrescriptionDrugCov GenIn/

  • HPMS Website

Updating CMS contact and labeler code changes

  • https://gateway.cms.gov - Website
  • CMS_IT_service_desk@cms.hhs.gov - Password Resets
  • CMSHPMS_access@cms.hhs.gov - Non-password access assistance
  • Independent Review Entity (IRE) for Discount Program appeals.
  • https://cgdpappeals.provider-resources.com/Default.aspx - Website