The National Community Pharmacists Association’s (NCPA) Vice President of Pharmacy Policy and Regulatory Affairs Ronna Hauser, Pharm.D., offers insight into challenges that pharmacies are facing right now, including retroactive fees and challenging Medicaid managed care reimbursements.
Ending retroactive fees is one of NCPA’s top priorities, according to Hauser, who reports that there is a proposal on the table at the Centers for Medicare & Medicaid Services (CMS) that would end the retroactive nature of pharmacy DIR fees potentially starting as early as contract year 2020. But right now pharmacy DIR fees and the uncertainty they create are here to stay for 2019, especially for Part D claims.
Hauser also reports that the NCPA is focusing heavily at the state level on issues with Medicaid managed care programs and underwater reimbursements There’s little transparency in the contracts between the states and the managed care organizations (MCOs), with the result that if you try to chart the connections between states and MCOs, you end up with a complicated web of relationships that can leave it unclear which plan a pharmacy is truly filling a given prescription for. Hauser notes an example in which a state was contracted with two different pharmacy benefit managers (PBMs), not realizing the overlapping services that were being paid for. With Medicare Part D and Medicaid making up more than 50% of a typical NCPA member’s business, it gets to be a big headache trying to submit clean claims and reconcile reimbursements.
Then there are new CMS Part D rules for opioid dispensing safety edits that went into effect Jan. 1, which now require hard safety edits for seven-day initial fill limits for opioid prescriptions for the treatment of acute pain and an opioid care coordination edit at 90 morphine milligram equivalents (MME) per day for certain beneficiaries. This is something that likely won’t have a major impact on pharmacy operations, but it’s another detail that you need to be sure you are attending to.
Learn more and download a PDF of the CMS memo “Additional Guidance on Contract Year 2019 Formulary-Level Opioid Point-of-Sale Safety Edits” and visit www.ncpanet.org/advocacy for other information and resources. CT