PDA provides the most comprehensive ongoing RDS administration and reopening services available. Our unique approach brings together all aspects of the RDS program from basic documentation and data gathering, to eligibility management and claims processing, to and filing reopening appeals and completing final reconciliation. Our process allows PDA to provide maximum value in subsidy dollars received with minimal effort on the part of our clients.

What Makes Our Process Different?

One of the most common frustrations Plan Sponsors have with the RDS program is the complex and confusing nature of program regulations as enforced by the Center for Medicare and Medicaid Services (CMS). Contradictory, ever evolving eligibility, claim and prescription drug requirements make it near impossible for Plan Sponsors to get 100% of the subsidy they’re eligible to receive. Fortunately, PDA’s sole focus over the past ten years has been staying current with the CMS requirements and developing a system that simplifies the process and maximizes plan sponsor subsidy in three key areas.

How We Find More Subsidy

Our Process Member Elig Area One | Member Eligibility ▼

In order receive subsidy payments for eligible expenses, retirees must be submitted to the CMS for approval. No matter how meticulously kept eligibility records may be, it is almost certain that there will be members who are “rejected” even if they fit the eligibility criteria for the program. So what’s going on?

The Medicare Database is the source of truth for determining RDS eligibility, which means if the information submitted to establish member eligibility (name, date of birth, social security number, etc.) is not an exact match to Medicare’s database, the member is rejected. Even more frustrating is the limited explanation for the rejection, which consists of a numeric code that corresponds to a vague rejection rationale. That’s it. But we can help.

Whether a Plan Sponsor is interested in traditional RDS services or looking to ensure their subsidy payments from previous years were maximized, for Part D Advisors, the process begins with improving member eligibility. To do this, PDA’s expert Business Analysts track down and consolidate member claim data from every possible source in a secure, customizable fashion. This data, once passed through quality assurance checks and loaded into PDA’s proprietary system, is used to assist Plan Sponsors with increasing their Retired Medicare Eligible Individual (RMEI) count by identifying members who were previously overlooked, leading to increased subsidy payments. Best of all, PDA can receive data through a variety of methods and can work with any file format, reducing the strain on clients and vendors.

Our Process Claims Matching Area Two | Claims Matching ▼

Given the rise in identity theft and other information security concerns, many in the health insurance industry have pushed to stop using member SSN and/or HICN information for claims processing. De-identifiers such as member or group IDs are often used in their stead. Because of this, the vast majority of claims (RDS eligible and ineligible alike) are received without a member’s SSN or HICN and claims that do have a SSN or HICN attached are often incorrect.

While this increases the security of private member information, it poses a major problem when submitting claims for RDS payments. In order to submit claims as eligible for subsidy under the RDS program, the CMS requires the claims to be matched by member SSN or HICN, a significant undertaking when you’re looking at potentially a year’s worth of claims.

By employing the same sort of alias matching process used for increasing a Plan Sponsor’s RMEI count, PDA’s one-of-a-kind system can improve the identification of claims processed under a de-identifier to the CMS required SSN/HICN identifying information. By matching these “orphaned” claims our process greatly increases the amount of subsidy for Plan Sponsors.

Our Process Drug Filter Area Three | Drug Filtering ▼

Prescription drugs are covered under either Medicare Part B or Medicare Part D and only those covered by the latter are eligible for the RDS program. Although the majority of prescription drugs are covered under Part D, a select few are covered by Part B under certain circumstances.

While the category for some prescription drugs is obvious, there are more than 6,000 prescription drugs with classifications that vary depending on when, where, who, how and why the drug is administered. In an effort to simplify the RDS process, the CMS offers a few options for Plan Sponsors to avoid painstakingly classifying each drug individually, each of them require an off-the-top reduction of pharmacy dispensed drug costs, meaning smaller subsidy payments. But there’s another choice.

PDA’s clients benefit from our custom-built filtering software, engineered with assistance from the nation’s leading pharmacy specialists. This filter allows us to review every claim for RDS eligibility by coordinating member medical and prescription claims to accurately categorize Part B and Part D drugs, adding considerable value in additional subsidy dollars identified and program compliance assurance.