Are you confident that your MCO provider is following the provisions in your state’s pharmacy contract as it was intended? Does the thought of going through the details of the contract and comparing it to the actual processes in place seem overwhelming? Through our successful work over the past four years performing Medicare Advantage and Part D prescription drug plan program audits with the Centers for Medicare & Medicaid Services (CMS), Myers and Stauffer has gained valuable insight into monitoring contract compliance with an MCO. We can help you feel confident in your program by monitoring your MCOs’ performance while ensuring their compliance with the delivery of prescription drug services. Services we offer include:
Formulary and Benefit Administration - Common deficiencies identified:
Rejecting claims for formulary medications as non-formulary.
Applying unapproved prior authorization (PA) criteria.
Applying unapproved utilization management edits.
Coverage Determination and Appeals - Common deficiencies identified:
Insufficient prescriber outreach to obtain supporting clinical information.
Misclassification of a coverage determination request as a grievance or general inquiry.
Failure to process requests and/or notify recipients within the prescribed timeframes.
For More Information
We encourage you to contact Lynsey Plew by email at email@example.com to arrange a discussion or meeting for more information regarding our MCO Pharmacy Contract Compliance Monitoring Program.
We have assisted our
clients in obtaining billions of
dollars in additional federal funding for their Medicaid programs through innovative provider tax, IGT, CPE
and UPL programs.