Healthcare Law, Jesse Dresser

Healthcare Law with Jesse Dresser

 

SUMMARY:

In this week’s episode of Attorney Talk, Ken Thayer interviews Jesse Dresser, who is a lawyer at Frier Levitt and practices in the area of healthcare law. Jesse deals with co-payment collection practices, mail order issues, and insurance billing practices concerning the running of pharmacies. Jesse routinely lectures to pharmacies and provides guidance about proper submissions of claims to insurance companies and methods of growing a pharmacy business while avoiding scrutiny from both payers and regulators. During the show, Ken and Jesse discuss general healthcare law, proactive versus reactive, PBMs, compounding and specialty pharmacies, Obama Care, and the future state of pharmacy law.

 

MAIN QUESTIONS ASKED:

  • What is healthcare law, and how do attorneys fit in the spectrum of pharmacy businesses?
  • Is yours more of a proactive position or after-the-fact where there are problems?
  • What is a PBM?
  • Are the PBMs gatekeepers for the insurance industry when it comes to pharmaceuticals?
  • Where does your practice come in?
  • What is the difference between compounding and specialty pharmacies?
  • Does a PBM get involved in compounding and specialty pharmacies, or do they deal more with scheduled drugs?
  • How do you get involved with compounding pharmacies?
  • Where do the conflicts get resolved?
  • Did your expectations of being a lawyer and reality meet up?
  • What do attorneys in general healthcare law do?
  • How has healthcare law changed in light of Obama Care?
  • In the area of pharmaceuticals and the Affordable Care Act, is there more of a push toward preventative care?
  • What is the future state of pharmacy law?

 

KEY LESSONS LEARNED:

Healthcare Law

  • Healthcare law involves representing providers of all kinds including doctors, surgery centers, hospitals, and pharmacies.
  • The source of income for providers is to bill the insurance company.

Reactive

  • Often, calls come from clients who have received audits, which are ssentially retrospective claims reviews being put out by insurance companies.
  • The PBMs may want to see all the claims, prescriptions, signature logs, and invoices for the past two years.
  • The reasoning is to substantiate the claims were billed in accordance with the underlying contractual documents and manuals, as well as state and federal law.
  • Responding to requests like this can be daunting for pharmacies.
  • Pharmacy lawyers can also assist in advising rights in the Pharmacy Benefits Manual or under state and federal law.
  • State laws often regulate how a PBM can conduct an audit of a pharmacy.

After Results Have Been Issued

  • The other time pharmacy lawyers get involved is after the results have been issued.
  • The PBM may find discrepancies, which the pharmacy has the opportunity to appeal.

 PBM

  • Pharmacy Benefits Manager.
  • This is a unique and niche claims reimbursement process.
  • Rather than do it themselves, companies such as BlueCross will farm out the management of the pharmacy benefit to companies called PBMs.
  • Express Scripts is independent, while OptumRx and Prime Therapeutics are owned by health insurance companies.
  • The responsibility is to manage a pharmacy network where the contract with a network of retail pharmacies is to negotiate drug prices for the various medications that will be covered.
  • They also manage what types of medications are and are not covered.
  • One of the ways PBM makes money is through the concept of spread pricing, where they charge the health insurance company one price but pay the pharmacy a lower price and keep the difference as an ‘administrative’ fee.
  • The overall mission statement is to manage the pharmacy benefit on behalf of their clients.

 Changing Industry

 Compounding Pharmacies

  • There has been a rise in compounding and specialty pharmacies.
  • Compounding pharmacies created custom-made medications for each patient.
  • Recently, there have been a lot more regulations with compounding pharmacies, as they serve an important and unique purpose within the overall healthcare system.
  • Compounds get an exception from the FDA labeling requirements, provided they meet certain statutory requirements.
  • Part of Jesse’s role is counseling pharmacies on how to meet those statutory requirements.
  • When billing the PBMs, the substantial record keeping needs to be addressed. There can be 25 different ingredients in one claim.
  • Jesse refers to this as quasi litigation, and goes back and forth with the in-house general council for the PBMs or insurance companies about whether or not the product should be covered and if the pharmacy complied with the manual submission requirements.
  • PBMs have created a restrictive network of pharmacies that are allowed to submit claims for these types of products.

 Specialty Pharmacies

  • Dispense high-touch, complex medication therapies that treat rare or unique diseases.
  • These therapies are often more expensive, so more attention is paid to them by PBMs and insurance companies than some of the generic medications.

Conflict Resolution  

  • Some call for arbitration in the home of the PBM HQ, and others call for general litigation.
  • Many are resolved behind closed doors, as they are pursuant to confidential contract arbitration agreement. Others are more visible because they are litigated in the federal court system.

General Healthcare Law

  • Some of the attorneys are regulatory, so they analyze state and federal laws and regulations as it relates to the regulation of healthcare.
  • One of the key laws is the anti-kickback statute, which prohibits remuneration in exchange for referrals.
  • Whistle blower lawsuits are on the rise, where the whistle blower gets to keep a percentage of the recovery as the relator of the case.

 Obama Care

  • There are a variety of ways that Obama Care has impacted healthcare law.
  • This is creating a new set of federal laws, as it pertains to plan design and management, and recovery guidelines.
  • One of the biggest changes is in putting a lot more people through the system.
  • Previously, there was a lot more ‘cash’ and non-insurance type business, now the system is a lot busier.
  • There has been a constant downward push on reimbursements in many areas.
  • There are more insured lives, so the practice focus has changed on high-dollar, high-value procedures to one that focuses on volume.
  • Shared savings models have been pushed via the Affordable Care Act.

 

The Future of Pharmacy Law

  • The pharmacy industry is dynamic, and will continue to be.
  • In the future there will be further development in the specialty pharmacies
  • We will see a lot more in the relation between manufacturers, pharmacies, and PBMs.

 

LINKS TO RESOURCES MENTIONED:

Frier Levitt

973-618-1660

jdresser@frierlevitt.com

 

CLICK TO TWEET:

How has Obama Care affected pharmacy law? Find out w/ @ FrierLevitt @gaylordpoppllc http://www.gaylordpopp.com

 What’ involved in being a pharmacy & healthcare lawyer? Find out  @FrierLevitt @gaylordpoppllc http://www.gaylordpopp.com

 

 

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