Martella’s has been a long-standing client and is local to many of our R.J. Hedges employees. Express Scripts attempted to terminate its contract with Martella’s. Their patients have filed a class-action lawsuit in Cambria County, PA, on behalf of Martella's pharmacies and its customers against Express Scripts, as well as the Highmark and UPMC insurance companies. We have not previously seen patients join in a lawsuit with a pharmacy to fight PBMs. We wish the owners, staff, and patients of Martella's good luck in this fight!
A Pennsylvania judge has issued a temporary injunction preventing Express Scripts from terminating its contract with Martella's pharmacies. The injunction allows the pharmacies to stay in network and patients to have access to their medications while the class-action lawsuit is litigated. See More…
Express Scripts is challenging this ruling, stating the case should be decided in federal court.
We’re excited to announce that our LTC at Home Compliance Program is officially available for purchase!
If your pharmacy delivers monthly medications, provides compliance packaging, and coordinates care for Medicare patients in their homes, you’re already providing Long Term Care at Home services! Now let’s make sure you’re getting paid for it.
Designed specifically for independent pharmacies, this self-service solution helps you:
Client-Exclusive Offer: 50% Off Through September 30, 2025
Congratulations to Wayne Myers and the entire staff at Carl's Drug Store for celebrating their 200 anniversary! They opened in 1825 and are one of the oldest continuously operated pharmacies in the country! Their celebration included awards from NCPA, the local Mayor, the Pennsylvania Pharmacists Association, and state legislators. As one of our longest clients at R.J. Hedges & Associates, we wish the fine folks at Carl's Drug Store many more wonderful years as a staple in their community.
CMS is considering a change to DMEPOS accreditation by increasing on-site surveys from every three years to annually. If the number of accreditation surveys increases, it is easy to assume so will the fees. Surveyors are paid for travel, meals, and expenses, plus the accreditation organization’s reviews and documentation will increase threefold. These costs will be assessed by the accredited facility. In addition, CMS wants to restart competitive bidding.
CMS has issued a Change Request (CR) is to inform contractors that effective June 9, 2025, contractors shall pay claims for Respiratory Assist Device (RADs) with or without a backup rate feature and Home Mechanical Ventilators (HMVs), in the home, as treatment for patients with Chronic Respiratory Failure (CRF) consequent to Chronic Obstructive Pulmonary Disease (COPD). The implementation date is October 22, 2025. See More…
After 4 months without permanent leadership, CDC has a new director in Susan Monarez. A scientist for the federal government for many years, she was nominated by the president and narrowly confirmed by the Senate on July 29th. Monarez inherits a former powerhouse in the public health space that is now facing deep budget cuts, growing criticism, a narrowing mission, and intense scrutiny amid a controversial shift in U.S. vaccine policy under HHS Secretary Robert F. Kennedy Jr. During her confirmation hearing, the first for a CDC director nominee under a 2023 law, she pledged to regain public trust in the agency, modernize data systems, and enhance preparedness for infectious-disease events.
Beginning Aug. 1, 2025, the Durable Medical Equipment (DME) ordering and fulfillment process in Alabama, South Carolina, Tennessee, and Virginia will be managed by Synapse Health for members with individual HMO and PPO UnitedHealthcare® Medicare Advantage plans, as well as Chronic Special Needs Plans (C-SNP). Additionally, the DME process for C-SNP plans in Georgia will also be managed by Synapse Health.
United Healthcare previously launched a capitated DME arrangement with Synapse Health for individual UnitedHealthcare Medicare Advantage members in Georgia and North Carolina, effective Sept. 1, 2024. See More…
Synapse Health’s 70-page contract (AL, GA, NC, SC, VA, TN Only) contains a section titled Fair Market Value and Commercial Reasonableness. The first sentence states: “The amounts to be paid pursuant to this Agreement have been determined by the Parties through good faith, arm’s-length negotiations to be the fair market value and are otherwise commercially reasonable.” There is a fee schedule, and a number of the products have a lower reimbursement, i.e., Blood Glucose Strips (A5253); the CMS fee Schedule is $8.32 per box; the Synapse fee schedule is $4.99 per box. Please review and know what the reimbursements are before dispensing.
On August 22nd, the FDA began daily publication of adverse event data from the FDA Adverse Event Reporting System (FAERS). “Adverse event reporting should be fast, seamless, and transparent,” said FDA Commissioner Marty Makary, MD, MPH. “People who navigate the government’s clunky adverse event reporting websites should not have to wait months for that information to become public. We are closing that waiting period and will continue to streamline the process from start to finish. FAERS is the FDA's primary database for collecting and analyzing adverse event reports, serious medication errors, and product quality complaints for prescription drugs and therapeutic biologics, containing reports submitted by health care professionals, consumers, and manufacturers. The shift is one of many steps in the FDA's broader data modernization strategy to streamline all its adverse event reporting systems and increase reporting frequency across all systems to identify safety signals faster. The public can view the latest adverse event data on the FAERS Public Dashboard. Health care professionals and consumers are encouraged to report adverse events to the FDA’s MedWatch site. See more...
CMS recently announced that all laboratories, including pharmacy-based laboratories with a CLIA certificate of waiver, must switch to email notifications by March 1, 2026. After that deadline, CMS will no longer mail paper fee coupons or issue paper certificates. Read the full statement from CMS Here…
CMS opened enrollment in June for the MTF-DM and sent invitations to NCPDP points of contact. During enrollment, the user will complete an agreement enabling the MTF system to access your NCPDP pharmacy information. Medicare is strongly encouraging pharmacies to complete their enrollment by November 15, 2025, to ensure information is accurate and avoid delays processing refunds. We are recommended everyone enroll by August 31- but there is still time.
Please reference our Bulletin in the Message Center of the Compliance Portal for more details.
Be on the lookout for audits from Pharmacy Benefit Managers (PBM) as they have audit authority over Medicare Part C and Part D. Optum recently added a section for LTC Pharmacy at Home within a Fraud Waste and Abuse Audit. At this point, the information requested is more like an attestation, but as more pharmacies expand into this service, we anticipate more requirements and requests in the future.
For more information on our LTC at Home Program please visit https://www.rjhedges.com/ltc-at-home
These two terms are often used in Compounding, Pharmacy, and DMEPOS operations and they can be easily confused.
Performance Management (PM)
Performance Improvement (PI)
Key Points
All these programs include specific tasks that must be completed throughout the year. If your facility operates across multiple disciplines (Compounding, Pharmacy, DMEPOS), you must complete all tasks for each discipline.
Immunizations:
DME:
Pharmacy: