Medicare Part D Consulting Services

Medicare Part D
and State Facilities
The Medicare Part D program for prescription drugs, launched January 1, 2006, significantly altered the manner in which state-run facilities are reimbursed for prescription drug expenditures.  Prior to that date, prescribed drug expenditures made on behalf of dually eligible residents of intermediate care facilities for persons with mental retardation (ICF/MRs) and institutions for mental disabilities (IMDs) were reimbursable from Medicaid. Medicare Part D is now the primary payer, and all facilities may only receive reimbursement for prescription drugs through the appropriate Medicare Part D program. 

The Medicare Part D system – designed primarily for retail and commercial pharmacies – often poses obstacles to state-operated facilities enrolling and operating in these networks. 

PCG’s experience in state-run facilities, as well as with the complex Medicare Part D system, allows us to help states successfully navigate the network enrollment process and maximize reimbursement for prescription drugs, efficiently and compliantly.

PCG Services

In many cases, state facilities are simply not equipped to recoup federal Medicare Part D funds.  PCG can help by setting up a comprehensive system to address key steps in the process, including:

Contracting and Networking
Medicare Part D involves a complex system of private third party payers that require each pharmacy be enrolled in their network for reimbursement.  Establishing contracts with each individual payer can be complicated and time-consuming.  PCG is experienced in enrolling state-operated pharmacies in Part D networks for all major plans. 

Eligibility Determination and Enrollment
PCG employs multiple methodologies to identify residents eligible for Medicare Part D, as well as the plan in which the resident is enrolled.  PCG can also identify residents who are eligible for Medicare Part D, but not enrolled, and can work with facilities to enroll these residents, realizing additional cost savings. 

Data Management and Claim Processing
Most state-operated facilities and pharmacies have limited or no data systems established for billing Medicare Part D plans.  PCG is well-versed with current data management systems for many facilities and can extract all of the information necessary for Medicare Part D claiming.  PCG uses advanced information technology to receive unprocessed pharmacy data to our data warehouse and organize it to meet requirements for industry standardized formats in real-time electronic claim submission. 

Claim Submission
PCG uses HIPAA-compliant secure software and a claims submission (“switch”) service uniquely designed for pharmaceutical claims submission.  PCG submits a claim and receives the response within seconds, cataloguing all claims data for further management and reporting. 

Rejected Claim Resubmission Management
For all claims initially rejected by Part D plans, PCG operates a robust system by which we receive a rejection, use internal staff to fix the rejection, and resubmit it.  PCG also offers a custom-designed web interface by which pharmacy staff can access, update, and resubmit claims for payment.   

Analysis and Reporting
PCG conducts thorough analysis of all claims, both paid and unpaid, to ensure that facilities are being reimbursed at optimal levels.  PCG provides a customizable suite of reports to better inform oversight agencies of problem areas and opportunities to improve their Medicare Part D claiming process.  PCG can determine whether plans are reimbursing at the contracted rate and identify which plans have the best performance in covering and reimbursing for the facilities’ most essential medications. 

Regulatory Analysis
Medicare Part D is still a relatively new program and is continually evolving and changing.  PCG maintains a high level of regulatory and policy expertise, enabling states to anticipate and adapt to all changes to the Medicare Part D system, ensuring optimal revenue and compliance. 

Among our clients:

• Illinois Department of Health Care and Family Services 
• North Carolina Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

PCG has been helping public hospitals achieve their performance goals for more than two decades.  Contact us to learn more about how our proven Medicare Part D consulting solution can help your facility.   

Attachments

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