By Lisa Howard, BS, CPM, CHP and Wendy Weingart, MS, RPh

In 2017, Centers for Medicare and Medicaid Services (CMS) will continue to focus on beneficiary protections, cost reduction and increased impact of non-compliance. With ongoing efforts to improve beneficiary protections, CMS will continue its changes to the Overutilization Monitoring System (OMS) with a focus on POS enhancements. In the 2017 Call Letter, CMS expects Plan Sponsors to develop formulary-level cumulative MED (morphine equivalent dosage) POS edits based on opioid overutilization. This would include a soft edit at no lower than 90 mg MED and a hard edit at no lower than 200 mg MED. It is also expected that Plan Sponsors minimize false positives by accounting for valid exceptions, such as hospice care, some cancer diagnoses, the overlap of prescription fills and high dosage amounts previously determined to be medically necessary.

Beginning in 2017, Plan Sponsors may opt to remove the extended days’ supply (2-3 month) on the first fill for selected drugs. This option will allow cost savings when a patient starts a new therapy and experiences a change in dosage, lack of clinical response, or discontinuation due to adverse side effects. In these cases, an extended days’ supply would be wasted and result in unnecessary expense.

CMS will continue to issue non-renewal notices to Plan Sponsors achieving less than three stars for the past consecutive three years as a result of non-compliance. Last year, the Notices of Non-renewal were sent in February. CMS continues to use the same criteria and timeline for Plan Sponsors in 2017.

Medicare Parts C and D program audits remain a top priority for CMS to identify areas of noncompliance in Plan Sponsors’ program administration. Civil Monetary Penalties (CMPs) issued from audits continue to rise and CMS is adding in “aggravating factor” penalty amounts to a greater degree in an effort to increase compliance.

Additionally, CMS just announced an industry-wide 2017 timeliness monitoring project for Part C organization determinations and Part D coverage determinations and redeterminations, areas that give key beneficiary protections for access to essential medical care and/or prescription medications. This is resulting from timeliness performance issues consistently identified in these areas during Medicare Parts C and D audits.

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