November 25, 2013
By Ralph K.M. Haurwitz, Austin American-Statesman
Nov. 26–Austin Community College plans to reduce hours for some adjunct faculty members to avoid having to provide them health insurance under the federal Affordable Care Act.
Austin Community College To Trim Hours To Avoid Health Benefits
December 6th, 2013Reference Based Pricing – Lessons Learned From A Pioneer
December 6th, 2013
“………..reference pricing program involved intensive communication with enrollees and met little resistance from them. Along with steering patients to lower-price hospitals, the reference pricing initiative affected market dynamics……………”
Exchange Plan Networks Still A Mystery
December 5th, 2013
“Having a serious conversation about public exchange plan provider networks is difficult, because many of the plans are still creating their networks.”
Editor’s Note: Why do exchanges, or anyone else for that matter, need to have networks of providers? Allow consumers to seek and receive medical care from the providers of their choice. Whether you go to Dr. Smith or Dr. Jones, the insurance plan would pay the same. It’s that simple.
Pushing Back Against Prompt Pay Laws
December 5th, 2013
By Ashley Collins, Phia Group
You may be aware of recent growing efforts by providers and vendors to leverage prompt pay laws as they seek to obtain additional funds from you and benefit plans across the nation. In particular, we are aware of providers in Texas working hand-in-hand with aggressive local law firms to take advantage of the state’s prompt pay laws. One Texas law firm recently boasted that it is pursuing potential damages exceeding $865,000,000 and is now promising to pay a 20% referral fee to parties that refer providers to the firm. (FOR A COPY OF ATTORNEY SOLICITATION LETTER WRITE RISKMANAGER@RISKMANAGERS.US)
Health Insurance Tax To Raise Premiums – Fully Insured Plans To Take Hit
December 4th, 2013The Obama administration quietly finalized the Health Insurance Tax (HIT) over the Thanksgiving holiday weekend, a provision in Obamacare that will cost nearly $60 billion over the next five years and raise health care premiums by 3 percent.
Email String Exposes Rx Prices and Schemes
December 4th, 2013
Someone sent us an email string yesterday regarding an insured’s attempt to get a prescription filled. Apparently the patient was told by the pharmacy that his prescription was not going to be honored by the pharmacy benefit manager. Of course, the patient was not too happy and complained to HR:
INSURED: Elizabeth, the pharmacy is calling me that the medication Matthew is needing is not covered by the insurance? There are two medications (1). Levofloxacin 100 mg (2). Mometasone 0.6 mg. He would need a 30 day supply can you check on this for me?
ELIZABETH to PBM: Do you show anything in the system for XXXXXXX for these meds?
PBM TO ELIZABETH: I just wanted to let you that we received a fax early this morning. Our clinical department is reviewing the information, and we should have a determination shortly.
PBM TO ELIZABETH: We had one of our clinical pharmacists talk to the pharmacist at XXXX Family Pharmacy. We wanted to see if the pharmacist would submit a lower price for the medication, he is submitting a cost of $1,600+ when in reality the medication should only cost around $40…..but he would not. The main ingredient in this compound is usually around $5 per gram. The pharmacy is trying to charge $120 per gram on an expired NDC code (all drugs have NDC codes for claim processing). Because of this inflated charge, the pharmacist may say that we will not cover the compound. This is not the case. The compound is covered, but should only cost around $40. At this point we would normally suggest the doctor be called to try an alternative commercially available systemic antibiotic.
PBM TO ELIZABETH: XXXXXX Family Pharmacy is attempting to charge $1,579.97 on a compound for Levofloxacin powder. According to prices we have on all the ingredients being submitted, the total cost should only be around $40. Please advise if the plan wishes to override the cost for this member and allow the pharmacy to bill for the full amount.
ELIZABETH TO PBM: How is this applied? What are the directions?
PBM TO ELIZABETH: I’m sorry Elizabeth, but those questions will need to be directed to the member, or pharmacy. These are not options that are supplied on an adjudicated claim. The only fields provided are ingredient, quantity, day supply, and cost. Also, I tried to call the pharmacy earlier to obtain the ingredients, and they would not give them to me, as I am not the doctor, nor the member. Of course, little did he know I can see the ingredients, I just wanted to verify.
PBM TO ELIZABETH: Sorry, I had to have one of the pharmacists obtain the additional ingredients. Please see the ingredients, qty and cost being submitted by XXXXX Family Pharmacy: Levofloxacin Powder – 6.o quantity, $726, Mometasone Powder, 0.033 quantity, $6.17, Loxasperse Powder Base – 7.32 quantity, $841.80.
Editor’s Note: Between the email above and the one below, Elizabeth found another local pharmacy with more reasonable pricing
ELIZABETH TO PBM: Have you seen a claim come through? What was the final price on it and how much does the employee have to pay?
PBM TO ELIZABETH: Yes, the claim did pay. The group is being billed $63.57 and the member is paying $25. I guess the pharmacy was finally able to locate a cheaper NDC.
This story has a happy ending. One pharmacy was going to bill about $1,600 while another charged less than $100 for the same prescription.
Maxor Administrative Services Expands Operations Into Phoenix, Arizona
December 3rd, 2013
Maxor Administrative Services Expands Operations into Phoenix, Arizona
Maxor National Pharmacy Services Corp. (Maxor) is pleased to announce that it has completed an asset purchase agreement for certain assets of Trident Plan Administrators, a Third Party Administrator based in Phoenix, Arizona with clients in Arizona, California, Kentucky, and Nevada.
Maxor, based in Amarillo, Texas owns Maxor Administrative Services (MAS) which is a third party administrator (TPA) for self-funded health plans. MAS currently operates an office in Amarillo, and will now expand its operations to the Phoenix office, providing the same level of dedicated service to clients and members through both locations. In addition to expanding operations in Phoenix, MAS will be adding to its staff in Amarillo to help support the growth in both offices. MAS pursues and delivers innovative cost containment solutions that break the mold of traditional healthcare delivery to self-funded health plans, and the expansion furthers the growth of providing these services.
MAS offers the knowledge and flexibility that is needed for self funded health plans to effectively manage their employee benefits. As the landscape of healthcare continues to change at a rapid pace, employers continue to search for ways to provide a quality, cost effective healthcare benefits package for their employees. MAS has experience in helping employers find unique solutions such as reference based reimbursement models or unique plan designs utilizing more conventional network arrangements. MAS provides accurate financial information about each component of their employee benefit plan and allows the employer to act on that information by selecting the service providers that best meet the needs of the Plan and its members.
About Maxor National Pharmacy Services Corporation (Maxor)
Maxor is a multi-faceted pharmacy services company with operations located throughout the United States. Since 1926, we have grown into a nationwide provider of pharmacy and healthcare services, including MaxorPlus, Ltd., pharmacy benefit management services; Maxor Pharmacies, retail and mail order pharmacies; Maxor Specialty Pharmacy and IV Solutions, specialty pharmacy services and home infusion therapy; Maxor Pharmacy Consulting & Management Services, providing inpatient and outpatient pharmacy consulting and management services; Maxor Correctional Pharmacy Services, providing correctional pharmacy services; and PickPoint, providing intelligent pharmacy solutions for remote dispensing systems, “will call” systems, and electronic medication administration records; and Maxor Administrative Services, administration of employee healthcare benefits. For more information about Maxor, visit www.maxor.com.
For additional information, contact:
Lori Brown or Dodd Nolan
(806) 322-5920 – Toll Free: (855) MAXOR-TPA
Cell Captives And The Recycling Of Capital
December 3rd, 2013
“……The problem for a business desiring to use a Cell Captive is that it must either itself post adequate capital within Cell, or it must rely upon the Main Company to supply that capital. If the latter, the business must make sure that the Main Company is not recycling its capital, and indeed has adequate, otherwise uncommitted capital (known as “surplus”) available to provide capital to the Individual Cell…………”
See Forbes article – http://www.forbes.com/sites/jayadkisson/2013/11/16/cell-captives-and-the-recycling-of-capital/2/
The State Of Retail Clinics
December 3rd, 2013
CMS Posts Article Regarding Physician Fee Schedule
December 2nd, 2013Editor’s Note: We received this in an email this morning – a 20% reduction in Medicare reimbursement is not going to fly with many in the medical community:
“I did a little searching today and found that CMS posted an article for public inspection in the Federal Register on November 27, 2013 regarding the Physician Fee Schedule. Looks like it’s the Final Rule with a Comment Period. ”
”Bottom line: the CY 2014 PFS CF is $27.2006. This is a 20.1% decrease from 2013’s of $34.0230. I presume this will get lots of comments/press/backlash and ultimately, Congress will adjust it at the final hour, most likely after January 1, 2014 when it is set to be effective.”