Regular and adequate PBM oversight is one of the cornerstones of Medicare compliance. PBMs report PDEs to CMS but ultimately it is the Health Plan's responsibility to ensure that the PDE data being submitted to CMS on their behalf is accurate and adheres to CMS guidance regulations or face penalties.
"Sponsors should perform regular and adequate oversight of their PBMs and other delegated entities to ensure that they are complying with all CMS requirements." - 2011 Program Audit Findings & Best Practice (JAN 20, 2012)
A high CMS-PDE acceptance rate can give plans a false sense of security. When a PDE is accepted by CMS it doesn't necessarily mean that it is devoid of significant issues. During adjudication CMS applies basic validation tests which are meant to reject PDEs with obvious issues. On site PDE audits are used to check more complex situations such as verifying that the submitted PDE is using the CMS approved PBP or validating that the beneficiary is in the correct benefit phase in relation to claims history.
Unfortunately, many health plans discover deeper issues during CMS audits which can potentially have adverse financial impact. The Cadre360® PDE Reconciliation software is designed to identify outliers early and allow health plans to stop issues from forming into liabilities.
Cadre360® discovers previously undetectable issues due to its unique approach to oversight. Unlike other software, Cadre360® uses non-calculated PBM outputs, such as ingredient cost, for oversight. Calculated PBM generated values, such as patient pay, are verified through recalculation by Cadre360® software. We maintain independent member eligibility tables, formularies, PBPs, PCT – PDE reconciliation systems, TrOOP beneficiary accumulators, and TGCDC beneficiary accumulators. This independent verification allows Cadre360® to find outliers that would have been previously undetected. The most accurate way to oversee a data source as complex as a PBM, is to independently recreate the same systems that generate the data and compare the results.
Cadre360® recalculates each PDE from its original Rx claim transaction.
The Cadre360® PDE is then compared against the PBM generated PDE and outliers are identified.
Identifying and resolving PDE related issues is a challenge presented to all Part D plans. Undetected problems that linger for an extended period can multiply and put plans at financial risk. Plans should have processes in place that can identify and resolve issues quickly. Cadre360® is a user friendly and cost-effective solution that gives health plans the tools needed to identify and fix PDE issues before they form financial liabilities. Using CMS Guidance rule sets, Cadre360® completely recreates each PDE from its original Rx claim data. Cadre360® then compares its PDE results with your PBM results. Variances are easily spotted and many times corrections can be made before they have a chance to change into liabilities.
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