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DIR FeesDIR FEESMichael Silber2022-05-24T17:02:42-04:00
Breaking NewsThis section is a collection of news updates and articles affiliated with DIR fee reform. What are DIR fees?DIR fees are the result of a loophole in Medicare regulations. Often more than half a year after a pharmacy fills a Medicare prescription, payers are taking back money paid to pharmacies. Payers are claiming they are taking back money due to a pharmacy’s performance on so-called quality measures. However, these quality measures can be unknown, unpredictable, inconsistent, and outside of a pharmacy’s control. The federal Centers for Medicare & Medicaid Services says that the use of DIR fees has exploded by 107,400 percent between 2010 and 2020 – a dramatic increase from the 45,000 percent growth that CMS reported between 2010 and 2017. Inmar produced a white paper that describes DIR fees. DIR fees 2022?DIR fee relief must be part of the effort by Congress and the Biden Administration to reduce drug prices and to bring transparency to the system. In Medicare, DIR fees are inflating the amount that seniors pay for prescription drugs at the pharmacy counter. DIR fees also are further pushing pharmacies out of business. IQVIA estimates that between December 2017 and December 2020 almost 2,200 pharmacies closed nationwide. This is because payers are hitting pharmacies with extremely high surprise bills that can force pharmacies to provide drugs below cost. Addressing DIR fees also would help to reduce overall healthcare costs. How Do DIR Fees Increase Patients’ Costs?The amount that Medicare patients pay for a prescription drug is supposed to be based on the cost of the drug. However, payers often calculate drug prices without subtracting the dollars that are taken back from pharmacies. This inflates patients’ drug costs, because the calculation is based on a figure that is higher than what the plans really pay. What is being Done to Provide DIR Fee Relief?The Biden Administration’s Centers for Medicare & Medicaid Services (CMS) announced a proposed rule on January 6, 2022 that included crucial aspects of DIR fee reform. NACDS welcomed the announcement and issued March 2022 recommendations. Two March 2022 congressional sign-on letters by members the U.S. House and U.S. Senate also called for DIR reforms. More than 200 patient advocates, healthcare entities, and companies also sent a March 2022 letter calling for the finalization of the rule. The new rule – Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs – was finalized by CMS on April 29, 2022. The rule’s provisions affecting DIR fees will take effect January 2024. NACDS expressed appreciation for the new federal rule that will help improve transparency of exorbitant DIR fees and potentially set the stage for further reform that is crucial to improve predictability, fairness, and viability for pharmacies. Legislative efforts to bring about DIR fee reform also have been underway. The Pharmacy DIR Reform to Reduce Senior Drug Costs Act (S. 1909/H.R. 3554) was introduced in the current 117th Congress. The legislation mirrors legislative advanced in the prior Congress by now-Senate Finance Committee Chairman Sen. Ron Wyden (D-OR) and Sen. Chuck Grassley (R-IA). It would:
Sen. Jon Tester (D-MT), Sen. Shelley Moore Capito (R-WV), Sen. Sherrod Brown (D-OH), and Sen. James Lankford (R-OK) introduced the bill in the Senate; while Rep. Peter Welch (D-VT), Rep. Morgan Griffith (R-VA), Rep. Buddy Carter (R-GA), Rep. Vicente Gonzalez (D-TX), Rep. John Rose (R-TN), Rep. Raja Krishnamoorthi (D-IL), Rep. Diana Harshbarger (R-TN), and Rep. Abigail Spanberger (D-VA) introduced a similar bill in the House. Previously, the Trump Administration proposed DIR fee relief in November 2018, but it was not included in a Medicare rule that was finalized in May 2019. A legislative effort ensued in the 116th Congress to address the issue. The Senate Finance Committee‘s bipartisan drug pricing package, unveiled in December 2019, includes a provision establishing standardized and relevant pharmacy quality measures as well as audit and transparency provisions to hold payers accountable. It also includes claw-back fee reform – a significant addition from prior versions of the legislation. The legislation was not enacted prior to the conclusion of the 116th Congress. This issue has earned bipartisan and far-reaching support. In June 2021 the National Association of Chain Drug Stores, the National Community Pharmacists Association, the National Association of Specialty Pharmacy, the American Pharmacists Association, FMI – the Food Industry Association, and the National Grocers Association welcomed a letter from 249 organizations supporting the current legislation. A 30-second ad by NACDS makes the case for immediate DIR fee relief. Amid the legislative push, the regulatory front is not without some action. In February 2020, NACDS welcomed signals sent in a Medicare rule by the Centers for Medicare & Medicaid Services that a standardized pharmacy quality program should be created to help reduce patients’ out-of-pocket drug costs and to help patients maintain critical access to their pharmacies. Review an NACDS detailed one-pager that details how the adoption of a standard set of metrics and Part D plan guardrails would help achieve comprehensive DIR fee reform. This would allow CMS to apply pharmacy performance metrics across the entire Part D program and would provide pharmacies with greater business certainty, leading to resources being diverted from extensive DIR accounting/financial capabilities to more robust community pharmacy-led care interventions that advance quality and cost and improve patient outcomes. Moreover, beneficiaries would be better-assured access to the pharmacy of their choice to best meet their particular health care needs. Public Support for DIR Fee ReliefPeople trust pharmacies and their solutions for saving money. In a January 2019 survey conducted by Morning Consult and commissioned by NACDS, 69% of voters said they find pharmacists credible for drug-savings solutions. Also, 86% support relying on pharmacists’ expertise for public policy solutions in this area. An impressive 67% want to change rules by which payers reimburse pharmacies below cost and unpredictably. Page load linkWhich is the name of the medication error reporting program used specifically for hospitals select one?NEJM, 347, p. 1636. MEDMARX is an anonymous medication error reporting program that subscribing hospitals and health systems participate in as part of their ongoing quality improvement initiatives. Nationally, data from MEDMARX contributes to knowledge about the causes and prevention of medication errors.
What is the role of third party payers quizlet?Third-party payers manage or administer the pool of money from individuals who decide to join an insurance plan. 4. Third-party payers pay or underwrite coverage for health care for another entity.
Who typically acts as a middleman between the insurer and the pharmacy?He explains that PBMs act as middlemen between the insurance plans, drug makers and pharmacies. He says most consumers have no idea there's a PBM, not an insurance company, managing their prescription drug plans. MICHAEL CARRIER: There are three main PBMs that take up 85% of the market.
What is it called when a patient pays a set amount of money for their medication quizlet?Formulary. What is it called when a patient pays a set amount of money for their medication. Co-pay. A joint government program that helps with medical costs for those who fall under the national poverty level is called what. Medicaid.
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What is it called when a third party payer looks for inconsistent billing from a pharmacy?
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