Posts by Bernard M. Cassidy

Pharmacy Benefit Managers (PBMs) control pharmacy networks for a number of insurers and there are not that many PBMs, so a PBM contract is the sole gateway to a number of insurers for pharmacy service claims. However, the PBM role is not merely processing claims; they hold a great amount of power over pharmacies because PBMs set payment criteria and policies.

A Bill being considered by the Florida Legislature would allow for the use of automated pharmacy dispensing, allowing pharmacies to use what essentially amounts to vending machines to dispense medications. CS/CS/HB 59: Automated Pharmacy Systems would allow community pharmacies to locate machines at medical offices, employers or other locations outside of the pharmacy in order to provide convenience to patients to obtain their medications.

According to an investigation by Pro Publica, the system for assigning National Provider Identifier (NPI), the gateway to obtaining billing privileges for federal health care programs and private insurance, makes it fairly simple to commit fraud. The reason is nobody actually checks the credentials of those applying for an NPI number.

Although the goal of providing care is the same regardless of the payment arrangement, often the payment model requires different approaches to how that care is both provided and particularly how health services are documented. The underlying payment rationale of managed care and Medicare Advantage plans is providers are reimbursed for value and outcomes rather than the volume of services.