may 2014 manufacturer webinar
DESCRIPTION
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. CGDP Data Overview. Amanda Johnson, Director, Division of Payment Reconciliation. - PowerPoint PPT PresentationTRANSCRIPT
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
30
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 [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
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