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Response to RFP No. MED13002 State of West Virginia ... - DHHR

Response to RFP No. MED13002 State of West Virginia ... - DHHR

Request For Proposal #

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services Pharmacy Audit Projects Our team’s experience with State Medicaid pharmacy programs includes responsibility for the review of claims and medical records for fee‐for‐service Medicaid beneficiaries in five states under the Audit Medicaid Integrity Contractor for CMS. The reviews included inpatient records with associated high‐cost drug expense. The project required our team members to interface with state Medicaid personnel and have a thorough understanding of covered expenses and reimbursement methodologies in five states. We have audited managed Medicaid programs in more than 12 states. Our reviews included audits of high cost drugs, compounds and injectibles – pharmacy expenses prone to billing abuse and overpayment. Our findings in this area include impossible quantities/units, payments for unspecified drugs, payments for over‐the‐counter drugs or compounds, and inaccurate pricing. Our team has developed sophisticated algorithms for detecting overpaid pharmacy services. The projects also required an understanding of Medicaid coverage and reimbursement policies for multiple states. PRGX’s subcontractor, Sagebrush Solutions, has conducted more than 100 Part D audits on behalf of CMS. The audits encompass payments for prescriptions for dual‐eligible participants. Beneficiary co pays and Low Income Subsidy (LICS) amounts must be verified to supporting documentation for each sampled dual‐eligible participant. These reviews require our team members to understand Medicaid eligibility requirements, subsidies and coordination with the Medicare program. Sagebrush Solutions, conducted a project for a large specialty pharmacy to electronically match unapplied cash accounts back to specialty pharmacy claims and then process appropriate refunds back to the state Medicaid programs. The unapplied cash accounts occurred when medical providers received payments from multiple sources or were otherwise overpaid for their pharmacy services and the medical provider refunded the overpaid amount to the specialty pharmacy. Typically, the provider refunds were for overpaid amounts on Medicaid or Medicare beneficiaries. The project required programming expertise to match refund data to claims data, clinical knowledge about the dispensed drugs as well as a thorough understanding of the Medicaid payment processes In addition to Medicaid pharmacy, our team brings West Virginia more than 15 years’ overall pharmacy audit experience. Designed to ensure efficiencies across pharmacy operations, PRGX’s specialized pharmacy audit capabilities spans more than 15 years across more than 19 pharmacy retailers. We have recovered more than $300 million in recoveries. Our team has audited the PBM administration of numerous governmental and large employer pharmacy 19

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services plans. The reviews include data analysis, reviews of random and focused samples of pharmacy claims, and verification of rebate amounts. Pharmacy Fraud, Waste and Abuse Our audit team has conducted an extensive data analysis and fraud investigation into the pharmacy expenses for a large state workers compensation fund. The review included drugs obtained through the retail and mail order outlets for a national PBM and drugs dispensed in facilities, physician offices and through repackagers and compounders. Data from all of these sources was aggregated to develop profiles of beneficiaries and provides with aberrant drug profiles, especially of schedule II drugs. The result of the project was a list of the top prescribers, dispenser and beneficiaries, with supporting documentation regarding the patterns and relationships. The results were provided to the fund’s counsel for further action. Based on our pharmacy audit experience, the following are some tests that we have found to produce significant findings for waste, fraud and abuse: ♦ Claims paid on behalf of ineligible participants ♦ Participants where another payer is primary ♦ Systematic administrative issues, e.g. the fee schedule or drug price per unit has not been updated in the claims processing system ♦ Duplicate payments or duplicate services (through PBM and through medical program) ♦ Impossible quantities/units ♦ Issues with formularies and/or step therapies ♦ Too‐frequent refills ♦ Re‐packaging ♦ Inaccurate payments for compounds ♦ Inaccurate payments for unspecified drugs ♦ Drugs with street value ♦ Drugs that do not fit the diagnoses in the medical data for the patient Data Analysis The PRGX team has developed an extensive library of more than 700 algorithms including an extensive set of concepts for detecting waste, abuse and potential fraud in pharmacy data. When available, we have found combining medical, eligibility and retail/mail order pharmacy data to be a rich source of information for identifying aberrant patterns. Our team has more than 12 years of experience in pharmacy data analysis and audit from our varying perspectives. 20

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