2019 Agenda

August 20, 2019

7:30am
Registration and Networking Breakfast

8:45am

Chairperson's Opening Remarks

Ana Handshuh, Principal 

CAT 5 Strategies

9:00am

Monitoring Your FDR: Meeting Contractual Obligations and Compliance Goals

  • Review policies and procedures needed for obtaining greater vendor cooperation and compliance 
  • Understand challenges for fulfilling contractual terms and ways to secure adherence 
  • Review ways to validate performance measurements for ensuring compliance  

 

Julie K. Lappas, Attorney  

HALL, RENDER, KILLIAN, HEATH & LYMAN, P.C.  

 

9:45am

CASE STUDY: A Delegated Model Health Plan and How to Effectively Manage FDR’s

  • Understand how Inter Valley uses committees to manage its FDR’s and how that benefits both organizations 
  • Analyze obligations, goals and ascertain how to get there 
  • Reviews processes to manage risk with FDR and establish a relationship so they listen to you and learn what to do when your vendor is evading your requests 

 

Gail Blacklock, Director of Compliance 

INTER VALLEY HEALTH PLAN 

10:30am
Networking Break

11:00am

MA-PD Plans: Adjusting Approaches to Effectively Manage Part B and D Benefits

  • Review Regulatory Changes in Part B Program – Impacts for MAPD plans 
  • Describe what programs plans are implementing as a result of the regulatory changes 
  • Discuss the future of Part B and Part D – what’s next? 

 

Babette S. Edgar, Pharm.D., MBA, FAMCP, Principal 

BLUEPEAK ADVISORS 

11:45am

Proper Drug Benefit Adjudication

  • Understand what therapies should be focused on and hear examples of drugs within therapy categories that can move from B to D  so that you know what therapies should be focused on  
  • Understand regulatory loosening of B and D benefits and step therapy for Part B drugs  
  • Analyze ways of managing part D excluded D vs E (excluded drugs) 

 

Brian Wehneman, Director, Compliance and Risk Management | Healthcare Services

HUMANA 

12:30pm
Networking Lunch

1:30pm

Outline of Administrative Requirements for with the New CMS Guidelines and Protocols

  • Review new regulation about insurer approval of prescriptions totaling 90 or more morphine milligram equivalents (MME) per day, TBD and its recent change to a consultation between pharmacists and prescribers 
  • Examine how to comply with challenges of newly required discussion between the pharmacist and the physician and how your organization may need to change relevant processes 
  •  Summarize requirements for Drug Management Programs for potential at-risk patients and examine ways it will affect your members 

 

Julie Moses, Compliance Monitoring Consultant 

BLUECROSS BLUESHIELD OF TENNESSEE 

2:15pm

Understand New Guidance from CMS Regarding Opioids and How It Will Affect Your Current Policies and Procedures

  • Review policies to ensure new regulatory guidelines are in place for continued adherence  
  • Understand new opioid utilization protocols and drug management programs that will need to be implemented 
  • Review new changes to the OMS work from CMS and examine potential CY2021 impact to Medication Therapy Management Programs 

 

Ryan Davis, Manager, Pharmacy Medicare Programs 

KAISER PERMANENTE  

3:00pm
Networking Break

3:30pm

INTERACTIVE SESSION: Mock Audits 101—A Nuts & Bolts Crash Course

 

  • Review critical best practices for building and maintaining an effective mock audit program 
  • Understand who needs to be involved and learn how to develop a culture that embraces compliance and audit-readiness 
  • Analyze ways to master the basics of preparing flawless universe data to reduce the possibility of an infraction 

 

Ana Handshuh, Principal 

CAT 5 Strategies

4:30pm

Champagne Roundtables

Participate in an intimate conversation with your peers on one of the topics below.  Facilitators will provide 5 discussion prompts for the group.  Participants are encouraged to bring their own topics for a table discussion.

 

Example topics: 

  • Claims processing of vendors   
  • Low income grievances regarding copay’s  
  • When and What to Delegate 


Facilitators:
  

Ashley Smith, PharmD, BCGP, Manager of Pharmacy Services, SCO 

BMC HEALTHNET PLAN (Medication Adherence) 

 

Marita Nazarian Pharm.D. Director, Delegation Oversight

L.A. CARE HEALTH PLAN 

 

Richard A. Appel, Project Manager, Senior Segment 

CIGNA 

 

Tammy W. Owens, MHP, PMCRisk Management Audit LeadCompliance & Risk Management | Humana Pharmacy Solutions 

Humana Healthcare Services (Rejected Claims Management) 

 

Robert Shelley, Founding Principal 

LEAF HEALTH (PBM Contracting) 

 

Julie K. Lappas, Attorney  

HALL, RENDER, KILLIAN, HEATH & LYMAN, P.C.  (Offshore Subcontractors) 

5:15pm

Chairperson’s Closing Remarks

5:30pm
Networking Cocktail Reception

August 21, 2019

8:00am
Registration & Continental Breakfast

9:00am

Opening Remarks

Ana Handshuh, Principal 

CAT 5 Strategies

9:00am

Concurrent Sessions

9:00am

Provider Preclusion List Implementation –Ensuring Compliance in The Ever-Changing Regulatory Environment

  • Analyze and interpret the provider preclusion list  
  • Review regulations and ways to communicate changes across organization and FDRs  
  • Learn methods for managing implementation within your organization 

 

Richard A. Appel, Project Manager, Senior Segment 

CIGNA 

9:00am

Understanding the New CMS Financial Audit and the Now-Associated Penalties That Go with It

  • Review the purpose and recent changes of audit and how it differs from previous financial audits 
  • Hear about details from FirstCare Health and what CMS auditors were looking for 
  • Understand exception findings and corrective plans to better evaluate what you have in place 

 

Tammy Owens, Risk Management Audit Lead  

Compliance & Risk ManagementHumana Pharmacy Solutions 

HUMANA HEALTHCARE SERVICES 

 

9:45am

Concurrent Sessions

9:45am

Reporting, Benchmarking and Analytics to Support Your FDR Oversight Program

  • Review systems to accurately report information and avoid CMS red flags 
  • Analyze examples from clinical, financial and regulatory compliance programs 
  • Understand how the data can be applied to other aspects of quality control 

  

Scott Fries, Executive Vice President Pharmacy Solutions 

PULSE8 

9:45am

Auditing and Monitoring Part D Coverage Determinations, Appeals, and Grievances (CDAG)

  • Understand a CMS audit of CDAG and how to prepare for it 
  • Review Vendor vs Health plan responsibilities during C MS audit 
  • Define how CDAG monitoring impacts CPE audits  

 

Marita Nazarian Pharm.D. Director, Delegation Oversight

L.A. CARE HEALTH PLAN 

10:30am
Networking Break

11:00am

Concurrent Sessions

11:00am

Effective Resolution of Enrollee Grievances

  • Review new Appeals and Grievance guidance from CMS 2019 to ensure your organizations full compliance 
  • Learn about ways for resolving every issue in the complaint 
  • Review methods for ensuring correct classification of a compliant vs grievance 

 

Koren Stevenson, Director of Contracts and Compliance  
CENTER FOR ELDERS' INDEPENDENCE

11:00am

Review of Revised Tracer Formatting for Effective Documentation

  • Learn how to tell the complete story 
  • Review revised CMS tracer format and new rules that no longer require demonstration of 7 elements 
  • Analyze best practices for putting things in tracer form 

 

Tammy Owens, Risk Management Audit Lead  

Compliance & Risk ManagementHumana Pharmacy Solutions 

HUMANA HEALTHCARE SERVICES 

11:45am

Concurrent Sessions

11:45am

Achieving Compliance and Privacy with Your Delegated Vendors

  • Review how to analyze and implement comprehensive data sharing agreements 
  • Learn about updates to BAA language 
  • Review breach prevention protocols and what to do when there is a breach 

 

Jessica VanderZanden, VP, Compliance and Audit 

Network Health Plan 

11:45am

Changes in PBM Drug Manufacturer Audit for Drug Rebates

  • Review current Rebate Regulatory Status and the proposed rebate payment protocol and how it will affect drug prices 
  • Learn about risk reserve and how to analyze likely Audit Parameters 
  • Learn how to identify and avoid oversight challenges you may encounter to avoid prolonging problems in the future 

 

Robert ShelleyFounding Principal 

LEAF HEALTH 

12:30pm
Networking Lunch

1:30pm

Concurrent Sessions

1:30pm

Handling CMS Memo’s – Effective Communication with PBM Regarding New Protocols

  • Learn best practices for handling and disseminating new information to FDRs 
  • Understand ways to configure a system for new protocols 
  • Review tactical plans for the logistics; time management, who is handling the memo and how to follow up with FDR 

 

Ashley Smith, Manager of Pharmacy Services, Senior Care Options 

BOSTON MEDICAL CENTER HEALTHNET PLAN  

1:30pm

PANEL DISCUSSION: What Are You Doing to Monitor Internal Operations

  • Discuss how plans determine which areas to focus on and who conducts the internal monitoring 
  • Review ways different departments conducting internal monitoring report their results to compliance/internal audit and other areas of the health plan where they’re may be overlap potentials 
  • Analyze where and how do you document your internal monitoring 

 

Moderator  

Dan Piessens, CEO

RevealRx LLC 


Panelists
: 

Jessica VanderZanden, Compliance Director   

Network Health  

 

Julie Moses, Compliance Monitoring Consultant 

BLUECROSS BLUESHIELD OF TENNESSEE 

 

Richard A. Appel, Project Manager, Senior Segment 

CIGNA 

2:15pm

Concurrent Sessions

2:15pm

Auditing your PBM’s Prescription Drug Events (PDEs)

  • Analyze Chapter 9 requirements and apply them to PDE data 
  • Is your PBM managing eligibility related rejections? 
  • Understand CSCC operations related to PDE data and how it is interpreted 
  • Review Vendor vs Health plan responsibility and how to provide the necessary oversight 

 

Jeff Baker, Senior Consultant  

BLUEPEAK ADVISORS 

2:15pm

ROUND TABLES: Attendee Generated Content: Bring Your Own Topic

  • Connect and discuss on topics that did not make it onto the agenda 
  • Explore knowledge and experience of peers and glean information you can take back home for implementation 
  • Share findings amongst the group so you can hear what other people talked about and learn from their discussions 

3:00pm

Closing Remarks

Ana Handshuh, Principal 

CAT 5 Strategies