BUILDING THE PBM/VENDOR RELATIONSHIP

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Aaron Musgrove-Lecours Director, Pharmacy Operations

FDR Oversight: How Do You Do it (or Not)? 2015 Compliance Institute

April 19, 2015

BUILDING THE PBM/VENDOR RELATIONSHIP

Selling the idea of partnership

1. The right thing is good for vendor, plan and members

2. Educate on your membership 3. Integration

4. Common Goals

• Engage your vendor in quality

• Get them to appreciate the connection to customer satisfaction and business growth

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BUILDING THE PBM/VENDOR RELATIONSHIP

Selling the idea of partnership

4. Common Goals

• Share your organization’s story, have PBM share it with staff handling your account • Visit call centers, prior authorization

centers

• Speak with employees directly • Educate on your

membership-demographics, challenges, etc.

BUILDING THE PBM/VENDOR RELATIONSHIP

Selling the idea of partnership

4. Common Goals

• PBM staff- extension of your organization • Should share responsibility for your

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BUILDING THE PBM/VENDOR RELATIONSHIP

Selling the idea of partnership

4. Common Goals

• Establish and emphasize shared goals • If organization’s membership is happy and

PBM performs well, plan will likely grow, increasing revenue for vendor and plan

YOUR ACCOUNT TEAM

BUILD THE RELATIONSHIP

MANAGE AS “ONE OF YOUR OWN”

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MANAGE AS “ONE OF YOUR OWN”

Selling the idea of partnership

1. Weekly calls

2. Quarterly onsite visits 3. Clear expectations 4. Don’t abuse

5. Encourage proactive, collaborative relationship

• Operations • Clinical • Medicare

MANAGE AS “ONE OF YOUR OWN”

Selling the idea of partnership

1. Weekly calls

• Tour site and make note of operations • Interview operational staff familiar with

your account

• Review training programs • Meet with management • Provide information about your

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MANAGE AS “ONE OF YOUR OWN”

Selling the idea of partnership

1. Weekly calls

• How quickly do you expect a response? • Must some responses be handled faster

than others?

• Email and return call expectations • Establish who should be making requests

of account team

• Check-in on workload: opportunities for more self-sufficiency?

MANAGE AS “ONE OF YOUR OWN”

Selling the idea of partnership

1. Weekly calls

• “Catch more with honey”

• Limit wasteful, time consuming requests • Utilize client tools

• Frees team to handle requests you can’t do yourself

• Automated report delivery • Limit ad hoc report requests

• Set up subscriptions for special report requests

• Reports can take a lot of time from your account team’s day, cutting into time to address other issues

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MANAGE AS “ONE OF YOUR OWN”

Selling the idea of partnership

1. Weekly calls

• Frequent engagement with account team • Set clear goals

• Solicit input from account team to help achieve these goals

• Set tone of transparency

• Shared risk from a business perspective • Collaboration is key

• Large PBM often has more resources to leverage and this benefits both parties

• Philanthropic opportunities

VENDOR OVERSIGHT

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VENDOR OVERSIGHT

Areas of Oversight

1. Call Centers 2. Prior Authorizations

3. Reject and Paid Claims Review 4. Site Visits

5. Formulary Administration and Pricing

• Listen to calls

• Have PBM inform their staff you are listening to calls

• Monitor metrics

• Set expectations for call center metrics across all lines of business • Medicare is good benchmark

VENDOR OVERSIGHT

Areas of Oversight

• Letter Review • Decision Review • Turn-around times

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VENDOR OVERSIGHT

Areas of Oversight

• Reject claim review daily for Medicare • Protected class follow-through • Reject and Paid claim review weekly for

other lines of business

• Reject review for oversight of formulary administration

• Paid claim review for oversight of formulary administration

• Coding errors= recoverable dollars

VENDOR OVERSIGHT

Areas of Oversight

• Call Centers • PA Centers • Specialty • Mail Order

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VENDOR OVERSIGHT

Areas of Oversight

• Formulary Updates on website

• Submission of formulary to State and CMS • Audit of pricing and formulary

• Coding errors and pricing errors frequent with PBMs

VENDOR OVERSIGHT

Areas of Oversight

6. Fraud, Waste and Abuse 7. Financials

8. Clinical Programs

9. Pharmacy Network/ other subcontracting 10.Policy and Procedures

• Establish relationship between SIU and PBM’s FWA unit, keep compliance officer involved

• Ride along on pharmacy audits

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VENDOR OVERSIGHT

Areas of Oversight

• Prior Auth. Billing • Clinical Programs Billing

• Invoice- Claims and Admin Billing

VENDOR OVERSIGHT

Areas of Oversight

• Meeting clinical objectives • Meeting ROI’s

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VENDOR OVERSIGHT

Areas of Oversight

• Attestation of compliance for downstream entities

• Attestation of credentialing and re-credentialing

VENDOR OVERSIGHT

Areas of Oversight

• Track and collect • Review Yearly

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TRACKING YOUR SUCCESS

AM I GETTING ANYWHERE?

TRACKING YOUR SUCCESS

Areas of Oversight

1. Monitoring 2. Document Everything 3. Stay Organized 4. Trends 5. Internal Audits • Daily • Weekly • Monthly • Quarterly • Annually

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TRACKING YOUR SUCCESS

Areas of Oversight

1. Monitoring 2. Document Everything 3. Stay Organized 4. Trends 5. Internal Audits • CAPS • Oversight • Reporting

TRACKING YOUR SUCCESS

Areas of Oversight

1. Monitoring 2. Document Everything 3. Stay Organized 4. Trends 5. Internal Audits • Shared Folders

• Central Location for all documents • Set a naming convention

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TRACKING YOUR SUCCESS

Areas of Oversight

1. Monitoring 2. Document Everything 3. Stay Organized 4. Trends 5. Internal Audits

• Areas with recurring issues • Areas with no issues

• Eliminate or reduce oversight

TRACKING YOUR SUCCESS

Areas of Oversight

1. Monitoring 2. Document Everything 3. Stay Organized 4. Trends 5. Internal Audits

• Is your program working?

• Can you provide information to regulatory entities efficiently?

• Surveying your membership • Specialty

• Benefit