Since the IRA went into effect in August 2022, manufacturers have struggled to understand exactly how the significant Part D benefit redesign and the resulting shift in expenditure between CMS, payers, manufacturers, and patients would impact manufacturer liability, payer coverage decisions, and contract negotiations. Here are 5 things you should be thinking about regarding Part D redesign and the upcoming 2026 bid cycle: 1) Payer economics of individual brands may vary based upon phase in eligibility 2) Dynamics within LIS and non-LIS require careful evaluation 3) Consider your multi-year bid strategy as phase in schedule changes yearly through 2031 4) Rebate dollars will become more valuable as payers are expected to retain a higher percentage of DIR in the years ahead 5) CMS’ expenditures in catastrophic coverage will decline but their direct subsidies to plan are expected to increase substantially Learn More: https://lnkd.in/dUiREnQW
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Since the IRA went into effect in August 2022, manufacturers have struggled to understand exactly how the significant Part D benefit redesign and the resulting shift in expenditure between CMS, payers, manufacturers, and patients would impact manufacturer liability, payer coverage decisions, and contract negotiations. Here are 5 things you should be thinking about regarding Part D redesign and the upcoming 2026 bid cycle: 1) Payer economics of individual brands may vary based upon phase in eligibility 2) Dynamics within LIS and non-LIS require careful evaluation 3) Consider your multi-year bid strategy as phase in schedule changes yearly through 2031 4) Rebate dollars will become more valuable as payers are expected to retain a higher percentage of DIR in the years ahead 5) CMS’ expenditures in catastrophic coverage will decline but their direct subsidies to plan are expected to increase substantially Learn More: https://lnkd.in/dUiREnQW
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If your organization is impacted by the Part D benefit redesign, we're here to help! You may find more information on key considerations below. #IRA #pharma #PartD
Since the IRA went into effect in August 2022, manufacturers have struggled to understand exactly how the significant Part D benefit redesign and the resulting shift in expenditure between CMS, payers, manufacturers, and patients would impact manufacturer liability, payer coverage decisions, and contract negotiations. Here are 5 things you should be thinking about regarding Part D redesign and the upcoming 2026 bid cycle: 1) Payer economics of individual brands may vary based upon phase in eligibility 2) Dynamics within LIS and non-LIS require careful evaluation 3) Consider your multi-year bid strategy as phase in schedule changes yearly through 2031 4) Rebate dollars will become more valuable as payers are expected to retain a higher percentage of DIR in the years ahead 5) CMS’ expenditures in catastrophic coverage will decline but their direct subsidies to plan are expected to increase substantially Learn More: https://lnkd.in/dUiREnQW
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Did you miss our live webinar covering the complex components of the Medicare Prescription Payment Plan (M3P)? It’s now available on demand. Watch now and download an M3P checklist to discover what program means for plan performance: https://lnkd.in/geiksKCC
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Get ahead of the Medicare Prescription Payment Plan (M3P) and tackle the operational changes required under the new program. Download our M3P checklist and access a detailed webinar on the M3P’s biggest challenges: https://lnkd.in/geiksKCC
Overcome M3P Financial and Operational Challenges
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Assistant Manager Operations at CloudRCM Solutions | AR Specialist | RCM Specialist | CRM Expert | Reporting Expert | MS Office Specialist | Auditor | Proficient in Using Softwares | Plan Maker | Negotiation Specialist.
Difference Between CPID and Payer ID Purpose CPID: Identify the payer for electronic claims processing. Payer ID: General identifier for healthcare payers. Assigned By CPID: Clearinghouse. Payer ID: Varies. Format CPID: Typically a 4- or 5-digit number. Payer ID: Can vary in length and format. Usage CPID: Electronic claims processing. Payer ID: Manual claims processing, looking up payer information.
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I hear a lot of EMS leaders calling for payers (usually CMS) to increase their reimbursement rates. I rarely hear these leaders explaining how they will return increased value to payers in return. From my vantage point, it seems like public and private payers alike are very cost sensitive, so simply saying "we need more money because our expenses have increased" does not seem like a winning strategy.
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Did you know that CMS is looking for feedback on how to operationalize the IRA negotiated price in the supply chain? The new Request for Information is an opportunity for stakeholders to help shape the potential role of a new entity, the Medicare Transaction Facilitator, charged to verify that only MFP-eligible individuals get access to the negotiated price to avoid diversion. Avalere is helping clients respond to the RFI, but also refine their business strategy around a number of open questions related to 340B discount non-duplication, patient cost-sharing, provider and pharmacy reimbursement, role of PBMs, etc. How the MFP is effectuated in the market is the question that will ultimately determine the administrative and financial burden for various players in the market. Reach out to learn more #avalere #IRA #Medicare #MFP #MTF Kelsey Lang Clayton Keene J. Lance Grady Omar Hafez
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2022 ACO REACH avg. gross margin (aka Direct Contracting in 2022) = 𝟮.𝟭% (𝗺𝗶𝗻 = -𝟴.𝟯%, 𝗺𝗮𝘅 = 𝟮𝟳.𝟭%, 𝗺𝗲𝗱𝗶𝗮𝗻 = 𝟮.𝟰%) With that gross margin, companies need to operate their business and generate returns on invested capital. For an ACO Entity that would consist of the operating expenses for the value based care team developed to support the ACO. These margins aren't yet high enough to sustain the capital invested. More work needs to be done on the total cost of care initiatives, but also on the operational side to optimize the REACH's network through participating provider lists and risk coding opportunities. ================================================= For context her are some gross margins for other business: United Healthcare's 2022 gross margin = 24.5% Medicare Advantage = 15% (max allowed by MLR rules) **For ACO REACH I am defining gross margin as net savings percent = 1- (claims / discounted benchmark)
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❗ Heads up: Labs and pathologists can now view their final eligibility status and requirements for 2023 Merit-based Incentive Payment System (MIPS) reporting. Individual reporting status is determined by NPI, although some providers may also face group requirements depending on their size. 👨⚕️ Providers who joined a new practice or assigned billing rights to a new tax ID during the year are most likely to see changes in their status from earlier this year. That said, it's a good idea to double-check your requirements to ensure you aren't hit with unexpected payment penalties in the coming years for failing to report quality and cost data. 💲 Remember, failing to meet the penalty avoidance threshold can result in penalties of up to 9% of your future Medicare Part B Payments! If you need assistance determining your reporting status or fulfilling your submission, don't hesitate to reach out to our RCM team! #MIPS #QPP #Medicare
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https://lnkd.in/e6Perik6 Per CMS, "effective January 1, 2024, providers and suppliers should no longer include AUC consultation information on Medicare FFS claims. However, claims containing AUC-related codes with dates of service in 2023 and 2024 will continue to process." - CMS is "instructing the MACs and SSMs to not reject or return advanced diagnostic imaging claims to providers with dates of service from January 1, 2024 ─ December 31, 2024, simply because an AUC Program G code or modifiers are submitted along with the advanced diagnostic imaging HCPCS procedure code." - Make sure your billing teams are aware of the new CMS CR 13485.
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