PRL Client Communication Update January 2021

Hi, this is Cheryl Nelson, Vice President of Client Services at PRL. We want to improve communications with you and focus on providing content that is useful to you and your team in your daily work lives. This update you are receiving from Client Services is part of our new communication strategy to deliver that information to you in a concise and timely manner. In this update, we are covering updates to the Most Favored Nation Drug Pricing, the merger between Harvard Pilgrim Health Care and Tufts Health Plan, Telehealth for 2021, the Medicare 2021 Provider Fee Schedule, and more. Read on to learn about these important developments. 

Most Favored Nation Drug Pricing

The Trump Administration’s Most Favored Nation drug rule that was supposed to go into effect on January 1, 2021, is under a 14-day temporary restraining order filed by the Pharmaceutical Research and Manufacturers of America (PhRMA) and granted by the Maryland US District Court.  The US District Court in California as well as Regeneron, the maker of Eylea, were both granted preliminary injunctions as well. The Most Favored Nation rule creates a mandatory, 7-year payment model for the 50 highest cost drugs and biologics.  It would replace the existing reimbursement that adds 6% to the average sales price (ASP) with new pricing based on 22 different countries’ pricing plus a fixed payment to cover the cost of storing, handling, etc.

Unfortunately, the most favored nation model puts the burden on providers by slashing payments for the drugs they purchase but does not address the pricing charged by the drug companies.  As a result of the restraining order and the injunctions, the reimbursement methodology for the top 50 drugs will continue to be based on ASP plus 6%.  PRL continues to monitor pending developments related to the rules’ implementation and will update clients when more information becomes available.

Harvard Pilgrim Health Care and Tufts Health Plan Merge

Effective January 1, 2021, Harvard Pilgrim Health Care and Tufts Health Plan have combined and are officially one organization.  While there are no immediate changes for patients or providers, a condition of the deal required Tufts Health Plans to sell Tufts Freedom Plan.  This plan services New Hampshire patients and has been sold to United Healthcare. Harvard Pilgrim and Tufts have established a website to keep providers updated.  Click the link here to access the website and FAQs. PRL will continue to update clients as we learn more.

Telehealth for 2021

PRL has been receiving questions from clients about CPT changes for Telehealth in 2021.  There have been no changes to CPT codes for telehealth. Providers will still need to code for video/audio with the appropriate E&M code along with modifier 95.  Telephone visit codes, 99441-99443, should continue to be used for telephone visits only.

Medicare 2021 Provider Fee Schedule

The new pandemic relief package (Consolidated Appropriations Act, 2021) includes provisions for $3 billion into the physician payment schedule to reduce the impact of the Evaluation and Management changes implemented on January 1, 2021.  As a result, CMS will need to release an updated 2021 Physician Fee Schedule which is expected mid-January.

Medicare Sequestration Penalty

As part of the new relief package, Congress has extended the suspension of the 2% Medicare sequestration payment cuts through March 31, 2021.

Patient Deductibles Reset

As 2021 begins anew, so do patient deductibles and out of pocket expenses.  Currently, 75 million patients are enrolled in high deductible health plans and that is impacting all of us. We all know that patients don’t always understand their healthcare plan’s coverage or that their deductibles reset.  Might we suggest, that educating the patient before or during their visit will help to eliminate “surprise” bills?  While you may not know the exact amount the patient will be responsible for, reminding them that their deductible and out of pocket expenses reset and as a result, they will likely be responsible for paying for the visit.

Manage Patient Responsibility with Patient Payment Xcelerator

Knowing that patient responsibility and patient payment is a growing challenge for all of us, PRL is offering clients additional support managing patient responsibility in the form of a new service, Patient Payment Xcelerator (PPX). This service is driving consistent and impressive increases in client self-pay collections. PPX utilizes mobile pay technology and the personal touch of our Patient Experience team to educate and engage your patients.  Please reach out to your Account Manager to discuss trying out PPX.