February 9, 2017
AccessHealth
2015 Aetna true-up plan finalized
You may recall that direct and indirect remuneration fees (DIR) were a reimbursement component of the 2015 Aetna Medicare D contract.
In June 2016,Aetna provided to AccessHealtha final report of all 2015 Aetna claims that were assessed a DIR fee. AccessHealth performed an in-depth analysis and as a result disputed the application of the DIR fee on nearly one million claims. The dispute process between AccessHealth and Aetna continued for several months and was finalized on 1/30/17.
Now that AccessHealth has reached a final agreement with Aetna over thedispute with respect to some 2015 Aetna Medicare D claims, it is time to complete the true-up with the AccessHealth network of pharmacies.
AccessHealth will begin the true-up process 2/9/17, via our central payment process.
On the day AccessHealth completes the Aetna true-up process for your pharmacy, a one-line item, underthe plan name Aetna, with an RX # identified as Adj-Aetna, will appear on your remittance statement from AccessHealth. The corresponding payment amount will be equal to the total Aetna true-up amount for your pharmacy. Your payment amount will be negative or positive depending upon the calculated difference between your actual DIR amount and the amount collected from your pharmacy by Caremark in 2015.
If you receive your AccessHealth payments via check the earliest you will see the Aetna true-up take place for your pharmacy is 2/10/17.
Review of the 2015 Aetna DIR methodology
The DIR fee for each claim underthe 2015 Aetna Medicare D Plan was calculated as the difference between the adjudicatedamount and the contracted amount. The pharmacy payment of DIR fees was made to Aetna, via collection by Caremark, in the month following the adjudication of the claim. This payment methodology was part of a complex DIR calculation model by Aetna. The DIR amount collected, in your weekly Caremark remittance data, was a percentage Caremark applied to the approved ingredient cost of your Aetna Medicare D claims. Using this methodology, Aetna collected the anticipated amount of total DIR fees owed by AccessHealth pharmacies. The percentage used by Caremark to calculate the DIR varied by Aetna network. The DIR methodology used by Aetna for the 2015 plan year is the basis for the reconciliation at the pharmacy level, i.e. the difference between the actual DIR amount and the amount collected from your pharmacy by Caremark.
Should you have questions about your 2015 Aetna contract year true-up, please contact the AccessHealth customer service department at 800.824.1763, opt #2 or contact your RSM for further information.