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Prescription Drug Events: The Overlooked Factor in Star Ratings

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For Medicare Advantage plans, achieving high marks in Star Ratings each year is a complicated and uncertain process. As the Centers for Medicare & Medicaid Services (CMS) introduces new requirements, measures, and adjustments to how factors are weighted in the final calculation, health plans are asked to keep up with a lot just to maintain scores. For plans trying to gain stars, it’s even more challenging.

Medication adherence is of growing importance for CMS, influencing up to 25% of Part D ratings. When seeking out ways to improve quality scores, prescription drug events (PDE) are often overlooked, yet an important factor in a plan’s quality scores.

What are Prescription Drug Events?

Every time a Medicare beneficiary fills a prescription covered under Part D, a prescription drug record is created. CMS refers to this drug record as Prescription Drug Event (PDE) data. PDE records use CMS-defined standard fields to summarize prescription drug cost and payment data for paid Part D claims. It is separate from individual drug claims.

The PDE file is templated by CMS and Part D sponsors are required to send the data to CMS regularly. If a previously paid claim has been modified, the file indicates it with an Adjustment-Deletion Code that indicates if the PDE record is original (initial PDE submission), adjustment (reprocessed of prior accepted PDE), or delete (reversal of prior accepted PDE).

Accepted and Rejected PDEs

After receiving PDE files, CMS issues PDE Response Files. These files will include all records submitted and whether they were accepted or not by CMS. 

The PDE data accepted by CMS are used in the PDE reconciliation, which determines the final payment to Part D sponsors for the plan year. Therefore, the information submitted must be accurate and complete.  
Values for the PDE Status Code include the following:

  • ACC: The record is accepted and payable to the sponsor.
  • REJ: The record is rejected for incorrect data and not payable.
  • INF: The record is payable but requires informational edits due to unverifiable data. These claims should be reviewed for potential errors.

Types of Rejections

Broadly speaking, PDE rejections by CMS fall into two main groups:

  1. Rejections due to errors in the beneficiary data such as eligibility or member demographics.

  2. Rejections due to errors in the claim submission.

CMS provides the rejected PDE lists along with the error codes. Sponsors are expected to review, reverse, and re-submit with corrected information to get the PDE accepted by CMS.

Types of Reports from CMS

To help gauge PDE files’ quality, quality and accuracy, CMS provides Part D Sponsors several reports that they can use to check their status to program averages and to monitor progress in improving PDE submission and error resolution over time.

PDE Reports contain metrics based on Part D plan sponsors submitted, accepted, and rejected PDEs. There are two types of monthly reports delivered via Acumen:

  • Immediately Actionable PDE (IAP) Errors Reports list all the claims that CMS expects sponsors to make an immediate correction and resubmit. Generally, these are formatting mistakes, data inconsistencies, and failure to grant Low Income Cost Sharing (LICS) subsidies.
  • Eligibility Errors Reports list the cases in which there is a mismatch between the enrollment information on the PDE and CMS’s records.

PDE Analysis Reports alert Part D sponsors to data quality issues identified in accepted PDEs. CMS expects sponsors to review and research the validity of the submitted data and to take appropriate action (adjust, delete, reverse, or reprocess) to correct claims with invalid data.

Why PDE Corrections are important

Aside from the obvious and immediate financial implications of rejected PDEs, quality scores of Part D plans can be negatively affected as well. A PDE claim that is not accepted by CMS means that the claim which was processed at the pharmacy is not counted for reimbursement or for inclusion in the Part D quality measures, including Star Ratings measures that calculate adherence.

CMS allows about six months after the end of the calendar year to correct rejected PDEs to include them in their quality measure calculations. Developing a process to review and correct rejected PDEs throughout the year is a best practice that can yield positive results on several fronts.

Healthmine’s Expert Advisory Services helps plans wrap their arms around data requirements and processes to manage CMS needs more efficiently. To get started, reach out to the team at ConsultingProfessionalServices@healthmine.com.

Healthmine is the leading member engagement and rewards solution focused on empowering people to take the right actions to improve their health.

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