HEALTHCARE

Consulting Services for Pharmacy Benefi t Managers (PBMs)

ARE YOUR COMPLIANCE AND OPERATIONAL PROCESSES OPTIMIZED?

Medicare plans weigh numerous factors when choosing a pharmacy benefi t manager (PBM). Considerations are no longer limited to drug pricing and network strategies. High value is placed on a PBM partner that has high acuity in Medicare and that emphasizes and enforces compliance throughout all levels of the organization, particularly as new and evolving regulations, such as price transparency, are enacted. Additionally, a robust and eff ective compliance program similar to that required of health plans themselves establishes the infrastructure to proactively identify and remediate compliance issues and operational risks. As a PBM, you must ultimately be able to evidence the success of your eff orts by performing strongly against your contractual agreements and during audits executed by the health plan or by regulatory agencies, as well as achieving positive outcomes for health plan members.

Ankura’s team of consultants brings in-depth understanding of the many aspects of Medicare health plan and PBM relationship from both perspectives. Through our exposure to our vast and diverse client base, we have visibility into the pitfalls that are impacting many PBMs and health plans throughout the industry. Our team can help your PBM identify and convert challenges into industry best practices, meeting the rigorous and frequently evolving standards set by the Centers of Medicare & Medicaid Services (CMS) and the expectations of your health plan clients. We have experience in providing PBMs with support for CMS program analyses of operational processes, evaluation of oversight and monitoring programs, remediation of identifi ed issues, implementation and monitoring of corrective action plans (CAPs), and identifi cation and resolution of other compliance and operational issues, whether regulatory or contractual.

WHO WE ARE

Our team comes from diverse backgrounds in leadership, compliance, clinical, and operational positions at some of the largest and most innovative PBMs and health plans since the inception of Medicare Part D in 2006. Ankura consultants have served as Chief Compliance Offi cers, pharmacists, data analysts, auditors, legal advisors, and operational leaders, bringing a comprehensive perspective to the delivery of pharmacy benefi ts. Our experienced team of consultants understands what your Medicare clients are looking for in a PBM and what leading PBMs are doing throughout the industry, and we can prepare your organization to meet these expectations.

© 2020 Ankura Consulting Group, LLC

ABOUT US Ankura is a business advisory and expert services firm defined by HOW we solve challenges. Whether a client is facing an immediate business challenge, trying to increase the value of their company or protect against future risks, Ankura designs, develops, and ex-ecutes tailored solutions by assembling the right combination of expertise. We build on this experience with every case, client, and situation, collaborating to create innovative, customized solutions, and strategies designed for today’s ever-changing business en-vironment. This gives our clients unparalleled insight and experience across a wide range of economic, governance, and regulatory challenges. At Ankura, we know that collaboration drives results.

COMPLIANCE PROGRAM DESIGN AND IMPLEMENTATION: Ankura’s services include development, assessment, and improvement of compliance programs to align with the expectation of health plan clients. Our team has developed or supported PBMs in the development of monitoring and auditing programs, annual risk assessments, dashboards of key compliance metrics, and issue remediation and escalation processes.

AUDIT PREPARATION AND SUPPORT: With audit activity continually increasing, PBMs are more commonly audit ready at all times. Our team can provide support for your PBM in advance of, during, and following a CMS program audit, including quality validation and analytics of your data universes, “mock” program audits, issue remediation, root cause analysis, impact analysis, CAP development and implementation, Independent Validation Audit (IVA) preparation, and IVA testing. We can also help prepare your PBM for health plan first tier, downstream, or related entity (FDR) audits.

PROCESS OPTIMIZATION: We can also help your PBM implement best practices based on our review and evaluation of current operational processes in comparison with well-established industry standards in accordance with CMS rules, regulations, and guidance. We will help identify gaps and help you develop a remediation plan as needed. Our experi-enced team can also advise you on the creation or update of policies and procedures, process flows, and job aids to help you drive consistent sustainable solutions for your operations.

PROGRAM VALIDATION: Ankura has assisted PBMs with functional reviews and provided detailed feedback on im-provement opportunities to position PBMs at the forefront of the industry. Areas of focus by PBMs include but are not limited to:

DATA ANALYTICS: Ankura has extensive experience creating and evaluating large electronic data sets through relational databases and a variety of software including SQL, SAS, and other data modeling tools. Our team is experienced with all phases of data analysis, including data profiling/validation, data mapping, querying, and relating the range of available data across formats and platforms. Our analyses have included pharmacy claims utilization, prescription drug events (PDEs), DIR, and claims re-pricing and have leveraged our comprehension of National Council for Prescription Drug Pro-grams (NCPDP) and compendial drug databases.

HOW WE CAN HELP

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DOROTHY DEANGELIS, Senior Managing Director

+1.602.528.8076 Direct | dorothy.deangelis@ankura.comJEFFREY LOW, Senior Director

+1.602.528.8093 | jeffrey.low@ankura.com

HEALTHCARE

- Pharmacy governance models- PBM implementation processes

(e.g., health plan transitions from one PBM to your PBM)

- Operational and process reviews for delegated areas (e.g., Explanation of Benefits (EOBs), CMS Reporting, Medicare PlanFinder)

- Direct and Indirect Remuneration (DIR) / Rebates