Medicare Prescription Drug Payment Part D Final Payment Process

Business Challenge

With sky rocketing healthcare costs, the Centers for Medicare and Medicaid Services (CMS) are under intense scrutiny for managing the spending related to the Medicare Part D Prescription Drug Benefit. Funding Medicare’s Part D consists of a sophisticated set of transactions between CMS, insurance carriers, and third-party entities (pharmaceutical manufacturers, secondary payers, and others) that must be reconciled at the end of each contract year to ensure that the prospective payments made throu


Pacific Consulting Group with analytical support team members contributes to the annual payment reconciliation process by collecting and analyzing information related to Prescription Drug Event, Direct and Indirect Remuneration, Plan-to-Plan activity and attestations.  The PCG team identifies discrepancies and potentially inaccurate reporting and then reaches out to carriers based on analytical findings. The PCG team also produces simulations to estimate the effect of changes to payment data through corrected reporting on overall payments from CMS to plans.


The complexity of the Part D Prescription Drug Benefit payment model lends itself to inaccurate reporting by Part D sponsors with large financial impact of the Medicare Trust Fund. Through analysis of the multiple components of the Medicare Part D payment model, the PCG team is able to provide CMS with the data needed to accurately detect payment discrepancies and ensure financial integrity for the Medicare program.