CMS POINT OF SALE PILOT ‘
Michelle Juhanson, CHC, CHPC Director, Compliance & Quality PerformRx ‘
Shawn McHale, Pharm.D. Manager, Pharmacy Prior Authorization PerformRx
CMS PILOT GOALS & PERFORMRX PARTICIPATION
What options available to resolve certain point of sale (POS) claim rejections without the enrollee having to request a coverage determination from the plan?
CMS invited PerformRx
• Relationship
• Coverage determination policy excellence
• Stand-alone PBM
Other pilot participants
• Highmark BCBS
• CVS Caremark
• Martins Point Health Plan
CMS Pilot Goal
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CMS Expectations
Develop proactive process initiated without any action on the enrollee’s part in response to POS claim rejection – Exclude pharmacy-resolvable rejections
Identify 5 to 10 target drugs for the pilot
Meet with CMS throughout the testing period – Be creative
– Provide honest feedback and policy recommendations
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PILOT PROCESS & OUTCOMES
Initial development of process – Two weeks
Process refinement from CMS feedback & pilot experience – Four weeks
Time Investment Pharmacist: 30 min per case
Technician: 10 min per case
Research and reporting: 30 min per day
Administration: 4 hours per week
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CIQA (2)
Pilot administration & initial case review
Service Delivery (1)
Rejection report
Prior Authorization (5)
Casework
MTM/DTM (4)
Casework
Formulary/DUR (1)
Consultative support
Account Management & Marketing (2)
Client engagement
Executive Leadership
(7)
Vetting
Pilot Process & Outcomes
Selection considerations
Beneficiaries from one plan contract
Frequently rejected drugs between 6/1/15 - 8/31/15
Most requested drugs at coverage determination level
Products overturned on redetermination
*Intersection with Star Ratings goals high risk medications (HRM)
**Additional drugs added 10/1-10/4
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Lidocaine 5% Patch *NITROFURANTOIN
MONO-MCR 100 MG
Esomeprazole Magnesium DR
40MG *CYCLOBENZAPRINE
NEXIUM 40 MG CAPSULE
Patanol 0.1% eye drops
**NIFEDIPINE ER 60 MG TABLET
**Januvia (GCNS- 97399, 97398,
97400
Pilot Process & Outcomes Targeted Drug Selection
Simple workflow
Limited disruption to plan or beneficiaries
Calls to pharmacies to: confirm validity of claims
instruct pharmacies to stop submitting un-approvable claims
Calls to prescribers to: explain criteria
offer to initiate coverage process
determine medical necessity
*MTM processed HRM cases
PA processed all other cases
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Run reject report (daily)
Review rejections against claim HX for subsequent
paid claims
PA or * MTM consult with pharmacy and
Prescriber to determine medical
necessity
Notify prescriber of
outcome
Notify pharmacy of the outcome.
Instruct to either reprocess or cease claim
submission
Actions/ outcomes
documented for CMS report
Pilot Process & Outcomes
Average Case Processing Time - 5.38 days
CMS determined pilot eligibility
Approved: PerformRx confirmed member got a drug
Unapprovable: CMS/Plan rules prohibit coverage 9
Caseseligble forthe pilot
Cases thatbecame
coveragedetermin…
Caseswhere
coverageapproved
Unapprovable cases
Casesprescriberopted out
of…
Caseswhere
formularyalternativ…
Results 79% 16% 53% 47% 68% 37%
0%20%40%60%80%
100%
Tota
l Cas
es
Pilot Process & Outcomes
COMPARISONS, CHALLENGES, &
REWARDS
Comparisons Pilot v. Coverage Determinations
SIMILARITIES
Multiple and varied outreach attempts required to secure information from prescribers
PBM pharmacists making the ultimate decision on medical necessity
PerformRx PA platform (PerformPA) used to document and workflow process once cases transferred to the PA department
Professional resources, decision making process essentially the same
Underlying Part D formulary rules applied
DIFFERENCES
POS Pilot CD
Required multi-department approach
PA department only (prospective cases)
No decision letter to beneficiary required
Written and telephonic beneficiary notice required
Pharmacists notified of outcomes
Pharmacy not informed of decision or progress
Not subject to timeliness standards. No defined “exceptions” process
24/72 hour timeframes (excludes tolling for exceptions)
Ability to make and provide decision over the phone in real time
Verbal and written decisions made after
Process is time and labor intensive with limited automation
Getting clinical information from prescribers in a reasonable amount of time
Allotting extra time for pilot participants because not in current staffing model
Value limited in the 4th quarter because of low volume of rejections
Challenges
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Rewards
Coordinate & confirm care for 10 of 19 members
Demonstrating a benefit to beneficiaries and plans when pharmacies know our decisions
Working directly with CMS – ― Getting immediate feedback from leadership
― Innovation encouraged & our ideas taken seriously
― Flexibility to apply new techniques & timelines
Opportunity to present findings to more than 800 from CMS Central Office
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Rewards CMS Feedback
“You deserve the highest praise for the work you did on this Point of Sale Pilot. Your reports and presentations were an outstanding example of professionalism. Your efforts went beyond our expectations, developing new creative approaches in aid of our collaborative goal. The Part D program will benefit from this work, most particularly our beneficiaries. Your enthusiastic advice was always appreciated; and I learned a great deal from our interactions”
- Jeffrey Kelman, MMSc MD, Chief Medical Officer, Center for Medicare, CMS “We believe there will be a significant level of interest in the presentation of your findings ...You presented thoughtful and valid concerns about potentially implementing this type of a change across the program, while highlighting valuable lessons learned and offering a number of suggestions on how we might address certain POS issues, including leveraging related program areas such as MTM, e-prescribing and rejected claims review, and through improved plan/PBM communication with prescribers at the point of prescribing”
- Beckie Peyton, Division of Appeals Policy, CMS
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PUBLIC POLICY IMPACT
Investigate programs to increase prescriber accountability to prevent unnecessary POS rejections
Apply greater emphasis on point of care coordination to lessen the need for a retrospective POS process.
Enforce adoption of existing e-prescribing standards (NCPDP Formulary Benefits 1.0) with prescribers and point of care software vendors
Monitor rejections at the prescriber level to identify gaps in formulary awareness
Public Policy Impact What PerformRx Recommended
An ounce of prevention
is worth a pound of cure
-Benjamin Franklin
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What type of Program do we recommend?
Voluntary
Which drugs should be included?
• Allow plan choice of drugs and disease states (like MTM)
• Drugs that prevent hospitalization • “Clinically fragile” drugs • Not necessary for HEP C and other high-cost specialty drugs
When would this have the greatest benefit?
• When beneficiaries are new to a plan or benefit design
• If applied year-round some prescribers may expect Medicare plans to initiate all coverage determinations
Who else should be included?
Pharmacy involvement critical to success of our pilot and missing link in
coverage determinations
Who is best-suited to do the work?
Organization(s) that process coverage determinations and contract with network pharmacies
Will this save Part D money versus coverage determinations?
No. Plan costs likely increase- staffing and drug utilization
Plan size, member composition, and marketing strategy would define ROI
Public Policy Impact What PerformRx Recommended
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Policy Impact What CMS decided
CMS position and call for comment released in Draft 2017 Part C & D Call Letter
Policy Impact What CMS decided
Some of the areas CMS may explore based on the pilot experience 1. How CMS and Part D plans could reduce the volume
of rejected claims on the front end by resolving certain issues before the prescription is sent to the pharmacy, such as:
Encouraging electronic prescribing, particularly electronic prior authorization, or other efficiencies in the PA process for a subset of drugs where the information needed to satisfy the PA may be obtained in a streamlined manner;
Making formularies more accessible to prescribers earlier in the process
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Policy Impact What CMS decided
2. How plans could employ proactive processes to resolve certain POS issues without the enrollee having to request a coverage determination, such as:
Identifying an appropriate subset of rejected claims to target proactive outreach efforts;
Designing outreach processes in a way that maximizes value while managing plan, pharmacy and prescriber resources, and program costs.
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Final Thoughts
CMS still considering policy –
– look to final 2017 Call Letter and beyond
– Potential for increased program costs with flexibility for plan/member composition
PerformRx prepared to collaborate with plans, CMS, prescribers, & pharmacies
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Questions?
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