MEDICAID MANAGED CARE ORGANIZATION (MCO) PHARMACY CONTRACT COMPLIANCE MONITORING PROGRAM

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.

  • Usual Impacts: Usual Impacts: Recipients are unable to receive the formulary medication that the physician has prescribed, or they are required to incur additional out-of-pocket expenses in order to receive this prescribed medication.

Applying unapproved prior authorization (PA) criteria.

  • Usual Impacts: Recipients are required to satisfy unapproved PA criteria, which improperly restricts and/or delays their access to prescribed medications.

Applying unapproved utilization management edits.

  • Usual Impacts: Restrictions are placed upon the recipient’s access to medications that impose inappropriate limits upon their ability to receive the product at the prescribed dosing regimen.

Coverage Determination and Appeals - Common deficiencies identified:

Insufficient prescriber outreach to obtain supporting clinical information.

  • Usual Impacts: Recipients are unable to obtain their medication due to the lack of required clinical information, or they are required to incur additional out-of-pocket expenses in order to receive the prescribed medications.

Misclassification of a coverage determination request as a grievance or general inquiry.

  • Usual Impacts: Recipients are required to take additional unnecessary steps for the request to be initiated. As a result, they may be unable to obtain their medication or they are required to incur additional out-of-pocket expenses in order to receive the prescribed medications.

Failure to process requests and/or notify recipients within the prescribed timeframes.

  • Usual Impacts: Recipients experience a delay in obtaining their medications (potentially having a negative clinical impact) or are required to incur additional out-of-pocket expenses in order to receive the prescribed medications.

For More Information

We encourage you to contact Lynsey Plew by email at lplew@mslc.com to arrange a discussion or meeting for more information regarding our MCO Pharmacy Contract Compliance Monitoring Program.

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