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This BAT Does Not Have Wings (But It Can Send your Members Flying If Not Done Correctly)

As 2020 has been challenging on so many fronts, health plans will want to “put their best foot forward” on January 1, 2021. New members, new benefits, new formulary, new providers, new pharmacies, and maybe a new pharmacy benefit management (PBM) partner presents lots of change for health plans and members. Additionally, CMS will likely be returning to the pre-pandemic number of program audits and January-February data is crucial to compliance excellence in program audits.

Your PBM will likely provide a standard set of test scenarios for the pharmacy department staff to review between November 15 and December 31. Some PBMs will even perform initial testing. However, our experience has shown that this review and initial testing is not comprehensive and does not usually uncover all of the potential coding and formulary administration errors that could exist. A robust benefit administration testing plan should include at a minimum the following:

· Formulary/Non-Formulary/Part D Excluded

· Utilization Management

· Copayments, Coinsurance/Part D Accumulators

· Transition of Care

· Grandfathering and Look Back Logic

· Concurrent Drug Utilization Review (cDUR) and Safety Edits

· Reject Codes and Messaging

Don’t have new members standing in the pharmacy on January 1 unable to fill their prescriptions or experiencing problems due to coding of the Part D benefit. This does not make a good first impression and ultimately leads to plan dissatisfaction.

Rebellis Group experts have performed Benefit Administration Testing (BAT) for many clients over the past decade and would be happy to assist and support your efforts to have a successful and mostly uneventful 2021 launch.


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