By now, you’ve discovered how valuable it can be for Medicare Advantage (MA) health plans to validate and correct member records to restore underpaid premiums due to Medicare Secondary Payer (MSP).
Many MA plans, however, overlook the necessity to address Prescription Drug (Part D) open records with MSP.
Here are four important reasons to address Prescription Drug as part of your MSP process:
- To comply with regulation. This is the top reason to maintain accurate member records for Rx eligibility. CMS puts the burden on MA Prescription Drug plans to validate open MSP/Rx records on file with CMS for its members. Having an active validation process satisfies this compliance requirement. Medicare Advantage plans do get audited – and if they can’t prove proper validation, hefty fines can result. Be sure to manage your Rx validation with a software application that tracks history in case an audit is requested by CMS.
- To keep eligibility information accurate. Yes, it’s a challenge to maintain accurate eligibility data for your members, but it’s even harder to catch up on a backlog of outdated records. We’ve seen plenty of garbage data stemming from a lack of oversight. Addressing Prescription Drug continuously with MSP is a best practice to ensure member records are actively managed, which can deliver many downstream benefits.
- To pay Rx claims correctly. With poor quality or insufficient data, claims can get stuck. With too many open records requiring validation, claims get paid slowly – or sometimes not at all. For example: in contrast to medical claims that require only one number for claims payment, Rx claims require four numbers: RXID, RX Group, RX PCN and RX Bin. All too often, one or more of these numbers is missing, which holds up payment. Other number mismatches or invalid record types also cause delays. But when Rx data is accurate and complete, claims get paid smoothly and swiftly.
- To provide better member service. When drug claims are held up, health plans aren’t reimbursed and members can get stuck with bills. Sorting out these problems frustrates members, wastes time, and clogs health plan resources to investigate and fix the issue. When prescription drug claims are paid the way they should, everyone benefits. Plan Benefits Managers are more confident in their claims data, and members are satisfied with their prescription drug coverage.
To get started, evaluate your current MSP efforts. Is Prescription Drug covered in your MSP process? If not, why?
Our clients often cite bandwidth as a common issue. To their relief, we assure them that we’ve got it handled. We verify accuracy, find missing pieces of information, and send updated eligibility data ongoing. When it comes to Rx validation, we always advocate a proactive approach – it saves time and delivers a better outcome for all involved.
For more information, check out our Medicare Secondary Payer resource page for links to additional articles and insights about advanced MSP solutions.