The value of PDA’s Ongoing and Reopening Retiree Drug Subsidy services for plan sponsors is second to none. After more than a decade in business, the quality of PDA’s work and the financial benefit enjoyed by our clients has made us the established leader in RDS program administration marketplace. Our unparalleled expertise and industry relations arm PDA’s expert team with the knowledge and skills to handle every aspect of the Retiree Drug Subsidy program in a manner that is understandable, efficient and profitable for our clients.
There is no such thing as a CMS formulary of Retiree Drug Subsidy (RDS) eligible drugs, which makes filtering for eligible drug claims one of the most complicated portions of the RDS program for plan sponsors to handle. A general rule of thumb is that any prescription drug claim not paid for under the Part B benefit is considered Part D eligible. However, there are exceptions that require a deeper understanding of Rx and professional claims data, the broader Medicare program and Federal regulations. Because of this, most plan sponsors (as well as other RDS administration firms) rely on incredibly conservative PBM cost reports that leave out valuable claims eligible for subsidy.
To rectify this problem Part D Advisors (PDA) was the first RDS administration firm to develop our own Part D drug filter built to identify every eligible Part D claim. Over the last eleven years, we have invested hundreds of thousands of dollars in continuous maintenance of our filter, including a subscription to Medispan’s drug database and employing the nation’s leading pharmacy experts to update our filters on a monthly basis, ensuring PDA’s clients remain on the cutting edge.
When PDA says we offer the most comprehensive and exhaustive RDS administration in the market place, it means we handle every aspect of the RDS program on our customer’s behalf allowable under program regulations. Correcting membership rejections can be one of the most frustrating and time consuming aspects of the RDS program for any HR department, which is why PDA would never expect a customer to correct them on their own. Even if a customer’s eligibility was done perfectly prior to the reopening, the entire membership must be resubmitted and re-approved during the reopening process, meaning all the work must be completed again before additional subsidy dollars are collected.
The cost reporting process is likely the most complicated and work intensive portion of the RDS program. Plan sponsors who handle the RDS program on their own often rely on the cost reports provided to them by their PBMs, which costs them subsidy in two ways. First, the cost reports provided by PBMs are often overly conservative and rely on automated processes that toss out eligible claims and members worth hundreds of dollars due to demographic errors easily caught by the human eye. Secondly, if a plan sponsor hires an RDS administration firm that does not do their own cost reporting, they are paying the firm to handle their RDS obligations on the plan’s behalf, but also to maximize their subsidy dollars by identifying new claims and/or members overlooked by a PBMs conservative approach. In this scenario, the sponsor is losing out on monies owed to them from the RDS and paying for the privilege.
Part D Advisors was one of if not the first to establish our own in house cost reporting system that utilizes raw data received directly from a sponsor’s PBM, which gives PDA the ability to review claims and eligibility from multiple sources. The raw pharmacy and professional claims often contain member data with several variations that PDA can track and store in order to retain every potential member alias and link it back to an approved member record. This alias process allows us to create permanent paths back to an individual member, first by deploying our one of a kind member matching algorithm software and then by manual, human review. This combined review allows PDA to build a vast database of Social Security Numbers and Health Insurance Claim Numbers (HICNs) which are then used to improve membership and match up all claims for cardholder/contract groupings, significantly improving subsidy collection.
There is no known selection criteria for RDS audits. In fact, the CMS selection process for auditing RDS applications is believed to be an entirely random process, meaning plan sponsors should ensure they are receiving the most comprehensive and experienced audit support available when selecting an RDS administration vendor. To our knowledge, PDA is the only RDS administration firm to take part in a CMS RDS audit. We are now more confident than ever that our system is tried and true; having been put to the test when a large client, consisting of several thousand retirees, was selected for an audit.
The CMS audit took over 6 months, requiring hundreds of man hours to complete. However, because of PDA’s forethought, preparation, hard negotiations and Audit Readiness Team, the audit concluded with a finding of no adjustment necessary, meaning the plan sponsor owed no money back to the CMS. Best of all, this level of assistance and support was provided to the customer at no additional charge, something every PDA client can depend on.In 2014, one of PDA’s customers had their 2010 plan year RDS application randomly selected for audit by CMS. While some RDS administration firms lack the expertise and infrastructure to take on such a task, the ability to support and guide our clients through a Retiree Drug Subsidy program audit was and is a key pillar of PDA’s charter. As such, we have assembled an exceptionally qualified Audit Readiness Team staffed by: an ERISA attorney, health & welfare actuaries, RDS program leaders and experts in claims processing, vendor data and plan organization. Additionally, our policies, methodology and tools are designed to make such RDS audits a streamlined and manageable undertaking for our clients. It is this forethought and dedication and all-encompassing RDS administration services that our customer came through the audit with flying colors, retaining every penny PDA collected on their behalf.
As PDA is believed to be the only specialty RDS administration firm to have successfully completed a CMS RDS audit, we have established the industry’s best practices for audit preparedness. It is PDA’s standard practice is to retain all necessary records in an auditable form for the CMS-required six-year term. In the case of a reopening, commitment to data storage still stands even if the reopening is not approved by the CMS or if the customer decides not to pursue it for any reason. This storage includes all information collected for the RDS program; enrollment data, claims information, and rebates. This data is warehoused together in order to ensure that it can be quickly and easily consolidated and sent to the auditors directly from Part D Advisors, alleviating the burden for our customers and their vendors. Finally, in addition to storing these records for our clients, comprehensive audit assistance is included at no extra cost as part of PDA’s approach to the RDS program, meaning PDA will work to support our clients in navigating and successfully completing a CMS audit should one occur, at no extra cost for time, materials or travel.