may 2014 manufacturer webinar

May 2014 Manufacturer Webinar

Angela Stanley,CMS, Division of Payment Reconciliation

• CGDP Data Overview

• CGDP Appeals

• Website and Portal Improvements

• An EFT Reminder

• Live Q&A

Agenda

2

CGDP Data Overview

Amanda Johnson, Director, Division of Payment Reconciliation

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

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

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

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

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

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

2013 Ending Benefit Phase for EGWP Discount Eligible Beneficiaries

10

3%

69%

25%

3%

2013 EGWPDeductible ICP Gap Catastrophic

2013 Ending Benefit Phase for EA Discount Eligible Beneficiaries

11

0%

83%

14%

2%

2013 Enhanced Alternative PlanDeductible ICP Gap Catastrophic

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

Average Gap

Discount Amount

2011 $ 603.75

2012 $ 705.56

2013 $ 910.69

Average Gap Discount Amount per Beneficiary

13

Coverage Gap Discount Program (CGDP) Appeals

Independent Review Entity (IRE) for the Centers for Medicare and

Medicaid Services (CMS)14

Independent Review Entity for CGDP

Review appeals of denied disputes

15

CGDP Appeals

• Affirm the appeal – (disagree with denial)

• Deny the appeal – (agree with denial)

16

File TPA Dispute Correctly

17

Know the Guidance

18

• Not calculated correctly• Not calculated with accurate data• Explain why determination is

incorrect

Reason Codes

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

19

Reason Codes

• Aberrant Quantity• High Price of the

Drug• Last Lot Expiration

20

Reason Codes

• Marketing Category–Not NDA–Not BLA

• Excessive Gap Discount– Single– Cumulative

21

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

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

Appeals Received

24

Appeals by Reason Codes

25

Appeal Outcomes

26

DRN Outcomes

27

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

Denied Examples

• Supporting evidence absent–Non covered drugs– Excessive gap discount– Inappropriate doses– Excessive cost

• Prior Authorization present

29

Conclusion

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

received from the IRE

CGDPAppeals@provider-resources.com

30

CGDPAppeals@provider-resources.com

31

Website and Portal Improvements

Art Spaziano, ManagerPalmetto GBAMedicare Part D, CGDP TPA

• 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

TPAdministrator.comFAQ

34

TPAdministrator.comFAQ

35

TPAdministrator.comListServ Announcement

History

36

Manufacturer’s PortalBi-directional Pymt

Confirmation

37

Manufacturer’s PortalDetail Reports

38

Manufacturer’s PortalConfirmation Responses

39

EFT Reminder

Art Spaziano, ManagerPalmetto GBAMedicare Part D, CGDP TPA

• 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

Contact Information

Art Spaziano, ManagerPalmetto GBAMedicare Part D, CGDP TPA

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 43

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=/PrescriptionDrugCovGenIn/

• HPMS WebsiteUpdating 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