Part D Drug Spend: Reimbursements

Author : Medicare Compliance Solutions

 By Medicare Compliance Solutions 

 

Prescription Drug Event (PDE) records are the official records used by the Centers for Medicare & Medicaid Services (CMS) for Part D revenue  reconciliation, coverage gap discount payments, STAR measures, 1/3 financial audits, and CMS program audits. They are critical to your success in managing Part D of your Medicare Advantage Prescription Drug (MAPD) Plan or your standalone Prescription Drug Plan (PDP). And PDEs may even be used for risk adjustment in the future. Drug plan sponsors have attested that they will:

  • Submit timely PDE records (HPMS memo 05/16/2011);
  • Submit original PDEs within 30 days following Date Claim Received or Date of Service (whichever is later);
  • Resolve rejected records and re-submit within 90 days following receipt of rejected record status from CMS; and
  • Submit adjustments and deletions within 90 days following discovery of issue requiring change.

Although PDE submission and resolution are not part of the CMS program audit, their accuracy and completion have both financial and regulatory consequences. Drug plan sponsors have received Notices of Non-Compliance (NONCs) when they omit PDE submission for more than 30 days. Managing PDE requires data administration capabilities and processes.
Auditing PDE requires knowledge of payment calculations (HPMS Memo December 2013, rules #1, #2, #3 and #5). Cadre360®, for instance, is a tool that provides a robust software application to:

  • Verify PDE data files are submitted as processed in the adjudication systems and invoiced;
  • Validate all the financial data elements (CPP, NPP, GDCA, GDCB, LICS and Reported Gap Discount Amounts);
  • Track reprocessing PDE records and rejections including dashboard and graphic views of year-to-date PDE results so your finance department can reliably accrue for any deficiencies; and
  • Verify that True Out-of-Pocket (TrOOP) and Total Drug Spend Accumulation calculations are in accordance with CMS guidelines (so you can be ready for the 1/3 financial audit whenever the CMS auditors show up).


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