Pharmacy benefit managers PBMs play an important role in detecting and preventing fraud, waste and abuse. Their access to prescription claims submitted by thousands of pharmacies offers an unparalleled ability to audit and monitor claims within their respective networks. One tool — real-time, digital and desk audits —help employers and health plans save hundreds of millions of dollars per year. And most importantly, these tools ensure medication health and safety for members.
The Program would include discounts and rebates on certain prescriptions and, where offered, on selected clinic services.
The Program was being offered previously to customers who satisfied certain eligibility criteria and paid an annual fee to join, but Federal program beneficiaries had not been permitted to enroll.
In seeking the Advisory Opinion, the Pharmacy sought to modify the Program to extend it to Federal program beneficiaries as well. The Program would provide three categories of benefits: Members would receive coupons providing discounts on Pharmacy retail prices for specific items paid for entirely out-of-pocket by Members, where no insurer would be billed e.
In addition, Members would be eligible for guaranteed savings in the form of store credit for the difference between the membership fee and the total savings over the course of a year if savings are less than the fee.
Enrollment would be either online or in person, and the only requirements would be payment of the membership fee, that the Member be over 18 years, and that certain personal demographic information be provided including name, date of birth, address, phone number.
No pharmacy or clinic would bill or submit a claim to any Federal health care program or other insurer for discounted items.
Further, Members would not earn any additional credit, bonus or other reward for filling new or transferred prescriptions at a pharmacy or receiving clinic services. Although the OIG pointed out that the Pharmacy did not have a mechanism to prevent Members from claiming reimbursement from their insurance companies for items and services purchased at a discount, it reasoned that the Members were not likely to submit such claims in most circumstances.
However, the OIG noted that if a Member could only earn, redeem, preferentially accumulate, or use credits based on the purchase of federally reimbursable items and services, they would have reached a different conclusion. The OIG reasoned that the Program would simply allow Federal program beneficiaries to access the discounts and rebates, and that:Jan 10, · In addition, the federal government's enforcement of the healthcare reform law's day rule for returning overpayments, as well as pharmacy fraud, may grab attention this year, legal experts say.
Humana has an ongoing nationwide campaign to get the word out about how contracted physicians, other health care providers, and business partners can help with fraud, waste, and abuse detection, correction, and prevention.
Legal Aspects The legal aspects of Brazil are as large and diverse as their population. Brazil is currently a Federal Republic. Similar to the United States, it has three legislative branches, the executive, legislative and judicial (“South America: Brazil”, n.d.).
BHM Legal Aspects of Health Care 1. Using the Internet and other sources research the following case: Robert Ray Courtney, a former pharmacist, who owned and operated the Research Medical Tower Pharmacy in Kansas City, Missouri.
2. Provide a detailed account of the key facts surrounding the case. Make sure to include the following: a. Pharmacy benefit managers (PBMs) play an important role in detecting and preventing fraud, waste and abuse.
Their access to prescription claims submitted by thousands of pharmacies offers an unparalleled ability to audit and monitor claims within their respective networks.
For the purposes of this guide, prescription drug fraud, which falls under the broader heading of pharmaceutical diversion, is defined as the illegal acquisition .