Payer Update, August 2021

Payer Update

Working with the Payer Team and Hemophilia Alliance Network Services (HANS) a 2021 Case Study
by Jeff Blake

Many of us have been involved in this situation – at the beginning of 2021, one of our member HTCs could no longer provide pharmacy services to one of their patients because the patient’s self-insured employer health plan changed claims administrators from United Healthcare to a third-party claims administrator named Centivo. Effective with this transition, the employer decided to require the HTC’s patient to receive their bleeding disorders medication from a commercial specialty pharmacy. The HTC sent the prescription to the commercial specialty pharmacy and in early January the patient received their first dispensation from the pharmacy.

In early February, I received an email from one of our stop loss carrier relationships asking if we could help them with a large claim for a hemophilia member. The stop loss carrier told me the January 2021 dispense from the commercial specialty pharmacy was almost 18% higher than the last dispense from the previous pharmacy. They wanted to know if the cost of the medication had increased that much, which it had not. I explained if we could receive the necessary de-identified information we could determine if our HANS and HTC solution could help. The stop loss carrier did not have all the information we needed so we had an introductory meeting with the third-party claims administrator, Centivo. Centivo provided me the additional information so we could complete our analysis.

The de-identified data provided by Centivo included the prescribing provider and we determined the provider was at one of our member HTCs. I contacted our primary contact at the HTC and they recalled losing this patient because of this change. The HTC was willing to bill their same rate from 2020 with a minor increase because their acquisition cost increased. We presented this information to Centivo, the employer that provided the health insurance and the employer’s insurance broker. All parties agreed this was an excellent solution and an individual Letter of Agreement (LOA) was signed. The HTC began dispensing to the patient again in March.

The Centivo team was impressed with our solution – expert medical care at an HTC and integrated pharmacy services. Centivo has clients throughout the United States and they wanted to know if our solution could be managed on a national basis. We presented our HANS Payer Contract and the agreement will be finalized within the next 30 – 60 days. Centivo is excited to have a national solution for their members that have bleeding disorder claims and we are excited to have another HANS Payer Contract!

If you would like to learn more and discuss how the Hemophilia Alliance can assist you with your payer challenges and issues, please contact a member of the Hemophilia Alliance Team.

Also in this Issue…

Notes from Joe
· Washington Update

Legal Update
· Uniform Grants Guidance Procurement Standards: More Than Just Finding a Good Bargain

Washington Update
· Drug Pricing Update

Alliance Update
· Harmony in Hemophilia – HTC Wall of Walkers Unite Walk Challenge Update
· Update on New Member Meeting