Health Law Blog

FOR A LIMITED TIME ONLY, WE ARE OFFERING A DISCOUNT OF $250 ON OUR COMPREHENSIVE COMPLIANCE PACKAGES FOR HEALTHCARE PROVIDERS


If you are a HEALTH CARE PROVIDER IN THE STATE OF NEW YORK, you MUST BE AWARE that every healthcare provider billing or ordering over $500,000 per year from the NYS Medicaid program (including claims billed indirectly through third-party managed care organizations (“HMOs”) is required to adopt and implement an effective compliance program.  The requirement pertains to services billed directly by the provider as well as any indirect claims such as orders or referrals for ancillary services, claims for which are submitted to Medicaid, including but not limited to laboratory, radiology, and ambulette services. The Compliance Program applies to billings, payments, medical necessity and quality of care, governance, mandatory reporting, credentialing, staffing and other risk areas that are or should, with due diligence, be identified by every healthcare provider.

All providers are cautioned: A provider may be subject to sanctions and penalties, including revocation of enrollment in the NYS Medicaid Program, for failing to implement an adequate compliance program.  Putting together a Compliance Program that meets the requirements of the NYS Department of Health and the Office of Medicaid Inspector General involves a comprehensive professional review of your operations and compiling an extensive set of requisite documentation.

The NYS Medicaid Compliance Program must satisfy specific requirements set forth in relevant NYS codes and regulations.  When applying for initial provider enrollment in the NYS Medicaid program, in transfer of ownership applications and once per year thereafter, during the month of December, every NYS healthcare provider must demonstrate and certify to the Office of the Medicaid Inspector General that an adequate and effective Compliance Program has been implemented, which includes properly drafted policies and procedures that describe compliance expectations. 

December 2012 is an IMPORTANT DEADLINE!! Every NYS healthcare provider claiming over $500,000 per year must CERTIFY to OMIG that an adequate Program is in place by DECEMBER 31, 2012!

Experienced attorneys at the healthcare law firm of Sauchik Law Group, P.C. will take time to address any of your questions pertaining to implementation and certification of an effective Medicaid Compliance program as well as address any other healthcare legal issues you may be facing. 

CALL US today at 718-787-9500, visit our website at ww.mdrxlaw.com or email us at This email address is being protected from spambots. You need JavaScript enabled to view it.

March 2012 Medicaid Update, npscfe8.pdf, discusses major changes to the Medicaid Fee-For-Service and Managed Care programs.  Some of the topics discussed in the update are:

• Policy and Billing Guidance
  • New Benefit Year Begins April 1 for Medicaid Fee-for-Service (FFS) Enrollees - discusses when the current service year for purposes of service limits begins for Medicaid Enrollees
  • New York Medicaid Transportation Management for Fee-For-Service Enrollees in New York City  - discusses major changes to the transportation program for Medicaid Enrollees
  • New Edits for Original and Adjusted Delayed Claims  - discusses changes to the Delay Reason Codes
     
• Pharmacy Updates
  • Family Planning Benefits for Fidelis Care New York Members Billing Update  - discusses the availability of family planning coverage for Fidelis managed care enrollees under the Medicaid Fee-for-Service program
  • Preferred Drug Program and Frequency/Quantity/Duration (F/Q/D) Edits  - discusses various codes that are returned by eMedNY for rejections due to FQD program implementation
  • Clarifying Information for Medicaid Fee-for-Service (FFS} and Managed Care Pharmacy Providers  - contains questions and answers regarding the co-existence of Medicaid Fee-for-Service and Managed Care pharmacy benefits and the responsibilities of managed care plans and Medicaid

If you have any questions concerning these changes or other concerns regarding New York Medicaid Program, please contact our attorneys at 212-634-3650 or 718-787-9500, or email us at This email address is being protected from spambots. You need JavaScript enabled to view it.

Like many independent pharmacy operators, you have probably been following the news of the proposed $29.1 billion merger between Medco and Express Scripts.  It is now official: FTC has granted its approval of the deal.  The merger creates the largest PBM in the nation with the combined market share of 32%.  This is what it means for your store:

1.  Possibly lower reimbursement ratesOne of the purposes of the merger is to lower costs by forcing even lower reimbursements upon pharmacies.  Clearly, no independent pharmacy can afford to lose access to a PBM of this importance.  The combined PBM will be practically immune from competition and will be able to not only lower reimbursement rates, but to set trends for other PBMs to follow.  Although reimbursement rates may not fall immediately due to multi-year contracts, they will probably trend downward in the years to come. 

2.  More mail-order, less patient choiceThe merger creates the third-largest pharmacy operator in the nation, just behind CVS-Caremark and Walgreens--and all of its business is mail-order!  By combining its dominant position in the PBM market with the desire to strengthen its mail-order business, it is expected that Medco-Express Scripts will require more patients to use their mail-order services.  This will undoubtedly take away even more business from independents.

3.  Walgreens will again accept Express Scripts
Many independents benefited from Walgreens' decision not to accept Express Scripts.  This is, however, likely to change.  Walgreens will probably not want to jeopardise its relationships with Medc,o and is expected to begin accepting Express Scripts, which will be part of the newly-merged PBM.

4.  The new PBM's domination in the specialty drugs market
The newly-merged PBM will have a particularly strong position in the high-priced specialty drugs market.  This is where the push to use Medco-Express Scripts mail-order might be felt the hardest.  Reimbursements for these scripts are also likely to trend lower.  

5.  Future mergers likelyWith this merger successfully approved by the FTC, similar deals are expected in the future, leading up to further consolidation and less competition in the PBM market.

What can you do?Many pharmacy organizations and politicians have expressed their concerns about this merger.  You can visit http://www.toobigtoplayfair.com/ and http://preservingcommunitypharmacy.com/ to add your voice to those who rightly fear that the merger will stiffen competition, hurt independent pharmacies and patients.  Lawsuits are being filed across the nation to attempt to undo this merger. 

Share this and forward it to your friends in the industry.  It is not too late to act.

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We hope you will find this section of interest to you and your practice.