PAAS National® recently assisted numerous pharmacies that received an email communication from Express Scripts stating the pharmacy had inappropriately billed Part D claims while patients were in a qualified Part A stay. The communication cited CMS’s LTI Resident Report as the reason for the conclusion of erroneous payments.
Many pharmacies reported that the data did not seem to add up as prescriptions were dispensed to either retail patients or patients that were residing in nursing homes while on “private pay” and not on a Part A stay. PAAS helped pharmacies get in touch with the appropriate CMS regional office, Part D Plan Sponsor, and an Express Scripts audit manager to challenge the findings. Within a few days Express Scripts sent additional emails to affected pharmacies notifying them that the first email was sent in error.
Background on CMS LTI Resident Report
Every calendar quarter CMS provides a list of Medicare patients that have been enrolled in a Part A skilled nursing facility stay to Part D Sponsors. This list identifies the skilled nursing facilities where the beneficiaries resided, so that Sponsors (and their PBMs) can ensure network pharmacies are available to serve these beneficiaries.
Part D Sponsors can also use this list to prevent inappropriate Part D payment of drugs covered by Medicare Part A. Sponsors, and their PBMs, can implement prospective edits to reject Part D claims at point of sale when a beneficiary is enrolled in a Part A stay, and these can be used for retrospective reviews of paid claims to identify prescriptions that should have been billed under Part A.