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Part D Compliance: 3 activities that will make a meaningful difference

The CMS regulations for the Part D program which came into being in January 2006 must be tens of thousands of pages by now. There is a rhythm to the schedule that must be adhered to every calendar year…..beginning with Transition and ending with Benefit Administration testing. Part D Formulary Administration is also one of the most common areas identified as non-compliant during a CMS Program Audit. Three activities that may make a difference for your health plan and your members are the following:

Medication Reconciliation

Members moving from acute care to home, home to acute care, acute care to long term care, long term care to acute care, and home to long term care provide the possibility for many adverse events. These transitions of care must be managed carefully to ensure that the member’s medical and pharmacy care is as seamless as possible. Acute care facilities are required to perform discharge medication reconciliation for patients. How often does this information make its way to the member’s health plan? Not very often. Members may transition from the hospital to home or long term care with different prescriptions than the ones they took before they were admitted. Examples of potential problems are multiple prescriptions for same drug class (therapeutic duplication) or changes in dosage. All members should have a medication reconciliation after every transition of care. Home or telehealth sessions to coordinate the member’s current medication regimen and provide member education are optimal.

Rejected Claims Review

A daily review of the Part D rejected claims is like a daily temperature check of the adjudication system….possibly boring but nonetheless essential. CMS has recommended rejected claims review for many years. The August 2014 HPMS Memo “Common Conditions, Improvement Strategies, and Best Practices based on 2013 Program Audit Reviews” stated the following as a Formulary Administration improvement strategy:

Complete a review of 100% of rejected claims to identify and correct any formulary and transition errors and then periodically review rejected claims to ensure no new errors develop.”

Either the health plan’s PBM or the plan staff should review the rejected claims on a daily basis filtering for the rejection codes most often associated with member access issues.

Medication Therapy Management Program (MTMP)

The Comprehensive Medication Review (CMR) which is a required activity in the MTMP and a Star Ratings measure (CMR completion rate), is usually delegated by the health plan either to a vendor or the PBM. The health plan usually doesn’t realize exactly where they are on the percentage completion scale until the fourth quarter of every year. Then a scramble to increase the completion rate at a fairly high cost ensues with varying degrees of success. Closely monitoring the rate throughout the year will alleviate some of the need for the fourth quarter scramble but additional pharmacist resources are a good option to achieve additional percentage points.

If you would like our team of Pharmacists at Rebellis Group to assist your organization with any of the activities above, or if you would like to spend 30 minutes strategizing (gratis) with one of our expert consultants, send us a note at



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