In this interview, Craig Ford, SVP of sales for pharmacy and government at solutions at Health Market Science, talks with ComputerTalk’s Will Lockwood about the critical areas of the 2015 Centers for Medicare & Medicaid Services (CMS) Call Letter and the trends that are impacting pharmacy’s efforts to maintain prescriber records in the face of multiple state and federal regulations and to ensure that they are submitting clean, payable claims.

ComputerTalk: What are the key take aways for pharmacy from the 2015 CMS Call Letter

Craig Ford:
The first takeaway is that regulatory changes that impact retail pharmacy will continue as CMS and regulatory agencies make efforts to handle the increased scrutiny on payments made by the government for healthcare services.

Secondly, retail pharmacy needs a dependable way to meet these regulatory requirements with as minimal an impact on their business as possible. Certainly pharmacy needs to meet these requirements, but they also need a way to stay competitive to provide the best service to their customer base. More specifically to the call letter, retail pharmacy needs to begin ramping up their efforts to ensure that they include information for only those prescribers enrolled in Part D so that they can meet the regulations when they go live in June 2015.

CT: Has the rescheduling of hydrocodone had an impact on the need for compliance tools?
Yes. Retail pharmacies are faced with these types of changes on a regular basis. This complexity and ever-changing environment makes it more difficult for individuals to apply the right analysis to each script. In this case, since hydrocodone changed from schedule III to schedule II on Oct. 6, pharmacies have needed to add this new regulatory change to their evaluation of the prescription before submitting.

So, using automated compliance tools helps a pharmacy be consistent in its decisions, can greatly mitigate a pharmacy’s compliance exposure, and reduce the stress and time taken by individuals submitting prescriptions at the pharmacy. 

We simply notified our customers using our real-time verification tool, VerifyRx, that we were updating the schedule of hydrocodone combination products so that their decision logic would be consistent with the new regulations. Their use of a compliance tool greatly reduced their exposure and effort to comply.

CT: What’s the state of use of prescriber data enrichment in pharmacy? Is it widely used? For those pharmacies not using it, what does it offer

Nearly all of our customers request that their data be cleansed or enriched before they start using our MasterFile data – and we recommend it. Many pharmacies have built a prescriber database over the years, based on information they have gathered over many months or years. Often that data begins to contain many duplicate records or outdated information. In many cases, there is data that just has not been captured, like additional addresses, email addresses, etc. Not only can this data make it difficult to select the proper prescriber for the script, but it also can result in invalid NPI or DEA numbers being submitted to the third party. And if the pharmacy doesn’t know if the prescriber has a valid state license, their compliance risk is even greater.

The cleanse and enrichment processes allows a pharmacy to start fresh, with a set of data about each prescriber in their database that is as up-to-date and complete as possible. Any duplicate prescriber records are merged with each other, out-dated information is updated, and missing data is added to the prescriber’s record. This way, the pharmacy has the most up-to-date, accurate, and comprehensive data about their prescribers. The pharmacy will have valid IDs at the federal and state levels, demographic data (such as address, phone, fax, and email), and federal and state sanction data.

An important point with cleansing and enrichment is that we don’t simply replace their existing database, we enhance it so that existing records within their systems are improved and existing references to prescriptions are not lost.

Pharmacy’s also need to be aware that they need a process beyond this fresh start. They also need to be able to audit the data that is entered into the pharmacy system after the initial cleanse. So, they need an ongoing remediation of new data introduced. These ongoing remediation services are critical to make sure they don’t need another enrichment down the road.

CT: What do you see as the data management needs on the horizon and that should be on a pharmacy’s radar?

The pharmacy environment has become more than only data management. It really is about decision management. Regulations and enforcement are holding pharmacies to a higher and higher standard regarding their evaluation of each prescription and the prescriber’s prescriptive authority. Simply put, pharmacies need automated systems so they don’t have to worry about whether they have the right prescriber and data for their patients’ scripts. Our customers want to focus on their patients, not on the nuances of the multiple state and federal regulations and interpretations – and certainly not while they are trying to get a patient their medications.

So, pharmacies need to start off with the best prescriber data as possible. They need an easy way to keep that data accurate and up-to-date. But at least as important, they need an automated decision engine to use all of that data in the right way, in a consistent manner, and in a way that doesn’t require the pharmacy personnel to even know that this verification is taking place.

Pharmacies should also expect solutions that can offer support in the event of an audit from a regulatory agency or third party. The solution should, like our VerifyRx tool, quickly display the data and verification that took place on any given script. This traceability and audit defense capability will only increase in importance for a pharmacy’s compliance strategy.

And remember, a pharmacy should expect all of these tools to be unnoticed by their personnel so that patients get the best care possible. CT

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