May 2014 Manufacturer Webinar
description
Transcript of May 2014 Manufacturer Webinar
![Page 1: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/1.jpg)
May 2014 Manufacturer Webinar
Angela Stanley,CMS, Division of Payment Reconciliation
![Page 2: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/2.jpg)
• CGDP Data Overview
• CGDP Appeals
• Website and Portal Improvements
• An EFT Reminder
• Live Q&A
Agenda
2
![Page 3: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/3.jpg)
CGDP Data Overview
Amanda Johnson, Director, Division of Payment Reconciliation
![Page 4: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/4.jpg)
Discount Eligible Beneficiary Distribution
4
2011 2012 2013 20140
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
40,000,000
LICS vs Non LICS Benes Across Benefit Years
Non-LICS Bene CountLICS Bene Count
![Page 5: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/5.jpg)
Discount Eligible Beneficiaries in Defined Standard Plans
5
2011 2012 2013 2014 -
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
Defined Standard Benefit Plan - LICS vs Non LICS Beneficiary Trend by Benefit Year
Non-LICS Bene CountLICS Bene Count
![Page 6: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/6.jpg)
Discount Eligible Beneficiaries in Enhanced Alternative Plans
6
2011 2012 2013 2014 -
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
Enhanced Alternative Plan -LICS vs Non LICS Beneficiary Trend by Benefit Year
Non-LICS Bene CountLICS Bene Count
![Page 7: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/7.jpg)
Discount Eligible Beneficiaries in Employer Group Waiver Plans
7
2011 2012 2013 2014 -
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
EGWP -LICS vs Non LICS Beneficiary Trend by Benefit Year
Non-LICS Bene CountLICS Bene Count
![Page 8: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/8.jpg)
Quarter Beneficiaries Enter the Gap
8
2011 2012 20130%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
6.6% 8.6% 9.1%
24.6%26.8% 26.2%
36.7%35.0% 35.6%
32.1% 29.6% 29.2%
Q4Q3Q2Q1
![Page 9: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/9.jpg)
Discount Eligible Beneficiaries by Benefit Phase, Program-wide
9
2011 2012 20130
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
3,251,770
3,267,691
3,945,108
468,839
494,864
661,850
Catastrophic CoverageCoverage GapInitial Coverage PeriodDeductible Coverage
![Page 10: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/10.jpg)
2013 Ending Benefit Phase for EGWP Discount Eligible Beneficiaries
10
3%
69%
25%
3%
2013 EGWPDeductible ICP Gap Catastrophic
![Page 11: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/11.jpg)
2013 Ending Benefit Phase for EA Discount Eligible Beneficiaries
11
0%
83%
14%
2%
2013 Enhanced Alternative PlanDeductible ICP Gap Catastrophic
![Page 12: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/12.jpg)
2013 Ending Benefit Phase for All Other Plan Types Discount Eligible Beneficiaries
12
23%
62%
13%
3%
2013 All Other Plan TypesDeductible ICP Gap Catastrophic
![Page 13: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/13.jpg)
Average Gap
Discount Amount
2011 $ 603.75
2012 $ 705.56
2013 $ 910.69
Average Gap Discount Amount per Beneficiary
13
![Page 14: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/14.jpg)
Coverage Gap Discount Program (CGDP) Appeals
Independent Review Entity (IRE) for the Centers for Medicare and
Medicaid Services (CMS)14
![Page 15: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/15.jpg)
Independent Review Entity for CGDP
Review appeals of denied disputes
15
![Page 16: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/16.jpg)
CGDP Appeals
• Affirm the appeal – (disagree with denial)
• Deny the appeal – (agree with denial)
16
![Page 17: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/17.jpg)
File TPA Dispute Correctly
17
![Page 18: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/18.jpg)
Know the Guidance
18
• Not calculated correctly• Not calculated with accurate data• Explain why determination is
incorrect
![Page 19: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/19.jpg)
Reason Codes
• Duplicate Invoice Item• Closed Pharmacy• Not a Covered Part D Drug
19
![Page 20: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/20.jpg)
Reason Codes
• Aberrant Quantity• High Price of the
Drug• Last Lot Expiration
20
![Page 21: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/21.jpg)
Reason Codes
• Marketing Category–Not NDA–Not BLA
• Excessive Gap Discount– Single– Cumulative
21
![Page 22: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/22.jpg)
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 $2,307 22
![Page 23: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/23.jpg)
Excessive Gap Discount Cumulative Claims
Depends on secondary payers and their TrOOP status
2013 - maximum discount for multiple claims is $4,871
2014 - decreases to $4,667
23
![Page 24: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/24.jpg)
Appeals Received
24
![Page 25: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/25.jpg)
Appeals by Reason Codes
25
![Page 26: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/26.jpg)
Appeal Outcomes
26
![Page 27: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/27.jpg)
DRN Outcomes
27
![Page 28: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/28.jpg)
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
28
![Page 29: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/29.jpg)
Denied Examples
• Supporting evidence absent–Non covered drugs– Excessive gap discount– Inappropriate doses– Excessive cost
• Prior Authorization present
29
![Page 30: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/30.jpg)
Conclusion
• File your dispute correctly• File your appeal timely • Respond to communications
received from the IRE
30
![Page 32: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/32.jpg)
Website and Portal Improvements
Art Spaziano, ManagerPalmetto GBAMedicare Part D, CGDP TPA
![Page 33: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/33.jpg)
• 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
33
![Page 34: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/34.jpg)
TPAdministrator.comFAQ
34
![Page 35: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/35.jpg)
TPAdministrator.comFAQ
35
![Page 36: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/36.jpg)
TPAdministrator.comListServ Announcement
History
36
![Page 37: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/37.jpg)
Manufacturer’s PortalBi-directional Pymt
Confirmation
37
![Page 38: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/38.jpg)
Manufacturer’s PortalDetail Reports
38
![Page 39: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/39.jpg)
Manufacturer’s PortalConfirmation Responses
39
![Page 40: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/40.jpg)
EFT Reminder
Art Spaziano, ManagerPalmetto GBAMedicare Part D, CGDP TPA
![Page 41: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/41.jpg)
• 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
41
![Page 42: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/42.jpg)
Contact Information
Art Spaziano, ManagerPalmetto GBAMedicare Part D, CGDP TPA
![Page 43: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/43.jpg)
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 [email protected]
• Webinar slides will be posted to the TPA website• Suggestions for future webinar topics should be sent to
[email protected] • Questions related to dispute files, EFT information, invoice
corrections http://tpadministrator.com – Website• [email protected] - Dispute support
documentation 43
![Page 44: May 2014 Manufacturer Webinar](https://reader036.fdocuments.in/reader036/viewer/2022062812/568163e8550346895dd5517e/html5/thumbnails/44.jpg)
Resources
• Medicare Drug Benefit Group • Questions related to the Manufacturers Agreement, changes of
ownership, terminations, compliance / administrative-related issues, policy
• Email address is [email protected]• Discount Program Manufacturer’s Page
• http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/index.html?redirect=/PrescriptionDrugCovGenIn/
• HPMS WebsiteUpdating CMS contact and labeler code changes• https://gateway.cms.gov - Website• [email protected] - Password Resets• [email protected] - Non-password access assistance
• Independent Review Entity (IRE) for Discount Program appeals.• https://cgdpappeals.provider-resources.com/Default.aspx - Website