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Surprise CMS Move Will Cost Hospitals for Multiple Push Injections of Same Drug

AISHealth and the 3/6/06 Report on Medicare Compliance are reporting Hospitals are about to lose money for intravenous push injections because of a surprise move by CMS, experts say.

CMS said recently that hospitals can’t charge Medicare for more than one IV push injection of the same drug during the same patient encounter (HCPCS code C8952C), according to new guidance on billing for drug administration under the outpatient prospective payment system (OPPS). Only multiple injections of different drugs can be charged separately, according to the guidance, which comes in the form of answers to frequently asked questions (FAQs) and was posted on the CMS Web site in mid-February.

This is the latest in a series of OPPS drug administration changes to cause revenue and/or compliance challenges for hospitals.

Deficit Reduction Act Enacted!

Here are the highlights of the Deficit Reduction Act signed in to law on February 8, 2006:

• Fee for Services payments to physicians will NOT be reduced by 4.4%. Claims that have been already processed will be reprocessed. Retro payments will be paid through July 1, 2006.
• Increase in the base payments to ESRD facilities for 2006. Claims that have already been paid will be reprocessed.
• Hold harmless payments for rural hospitals will be reinstated.
• 5% add-on payment to rural home health services to rural beneficiaries
• Caps to outpatient therapy services went in to effect Jan 1 2006. $1,740 per beneficiary per year for speech and occupational therapy.
• Changes to rental arrangement for DME equipment. “Capped rental” equipment are rented by Medicare for 13 months (was 15 months) and the title now transfers to the beneficiary after the 13 month period. The title use to rename in the name of the DME rental company.
• Oxygen equipment is now rented for 36 months (was indefinitely) and the title transfers to the beneficiary at the expiration.
• The minimum number of days that a non-electronic claim will be paid changed from 27 to 29 day

COMPLETE MEMO FROM CMS

CMS Issues guidance on Part B vs. D Coverage

On a January 24, 2006 conference call Craig Miner and Lawrence Kocot issued guidance on how plans should and should not be determining drug coverage under Parts B and D.

“Part D plans should not be requiring a Part B rejection as their first step before they’ll start thinking about covering it under Part D,” Craig Miner, a pharmacist with CMS’s Division of Drug Plan Policy, told call participants. “In other words, they need to take further steps to see if there is reason to believe that it should be Part B [which covers outpatient medical expenses], and in that case, perhaps, they can get to the situation where it makes sense for them to say, ‘we’re not going to cover it under D unless there’s a Part B rejection,’” he said.

CMS will not reimburse for drugs that can be covered under Part B if they are billed as Part D. According to call participants, as a result, many plan sponsors are refusing to cover injectable and infusible drugs unless a Part B rejection is presented first.

Miner acknowledged that in some cases whether to request a Part B rejection is clearly a judgment call, and that CMS does not provide specifics on the issue. Instead, “I would say…what we would expect in general is that plans would have policies and procedures…[at] the level that is appropriate and necessary…to make B vs. D determinations,” he said. “It doesn’t have to be a one size fits all.”

CMS officials emphasized that Part B coverage has not changed, so that drugs previously covered under Part B — including immunosuppressants for patients who received transplants at a Medicare-approved facility, oral oncology agents used for cancer indications, and erythropoietin for treatment of anemia in dialysis patients — remain under Part B. CMS staff also clarified that inhalation drugs dispensed through machines in nursing homes, as well as diluents used for mixing drugs (but not saline and other flushes) are indeed covered under Part D.

One area of controversy surrounding CMS’s Part B vs. Part D policy is reimbursement for home infusion (HI) drugs. Under Part D, although the drugs themselves are covered, the related supplies, equipment and support services are not, creating billing problems, coverage gaps and confusion for plan sponsors, HI providers and patients. The National Home Infusion Association and its members are calling for HI drugs to be shifted to coverage under Part B.

A few Medicare Advantage prescription drug plans (MA-PDs) have crafted their own solution to the Part D HI problem, but it is not yet clear whether their policy will withstand CMS scrutiny. According to NHIA, at least two managed care organizations — Blue Cross Blue Shield of Massachusetts and Horizon Blue Cross Blue Shield of New Jersey — have made the decision to continue covering HI for their MA-PD patients as a medical benefit, instead of split-billing drugs and services.

View CMS’s Part B vs. D coverage guidelines at www.cms.hhs.gov/Pharmacy/ Downloads/partsbdcoverageissues.pdf.

Excerpts from AISHEALTH News of the Week

National Provider Identifier – Subparts

Implementation of the National Provider Identifier(NPI) is moving forward. We should stay on top of the current implementation calendar and recent CMS guidance.

Here is a link to the CMS site where there is a letter clarifying CMSs expectations on determining subparts to covered entities who should bill CMS using unique NPIs. Here is an excerpt clairfying how organizations should define subparts:

Generally, the type of service being reported on a Medicare claim determines the type of Medicare contractor who processes the claim. Medicare will expect an enrolled organization health care provider or subpart to use a single (the same) NPI when billing more than one type (fiscal intermediary, carrier, RHHI, DMERC) of Medicare contractor. However, in certain situations, Medicare requires that the organization health care provider (or possibly even a subpart) enroll in Medicare as more than one type of provider. For example, an ambulatory surgical center enrolls in Medicare as a Certified Supplier and bills a carrier. If the ambulatory surgical center also sells durable medical equipment, it must also enroll in Medicare as a Supplier of DME and bill a DMERC. This ambulatory surgical center would obtain a single NPI and use it to bill the fiscal intermediary and the DMERC. Medicare expects that this ambulatory surgical center would report two different Taxonomies when it applies for its NPI: (1) that of Ambulatory Health Care Facility—Clinic/Center–Ambulatory Surgical (261QA1903X) and (2) that of Suppliers—Durable Medical Equipment & Medical Supplies (332B00000X) or the appropriate sub-specialization under the 332B00000X specialization.

Medicare and Pay For Performance

P4P is already on its way and most organizations that manage Medicare lines of businesses are not preparing for the changes in data collection and reporting. Here is a good article outlining the P4P programs already in demonstration with CMS and where they are headed. Now is the time for us to pay attention and begin planning and preparing.

Want To Create A New Medicare Plan in 2007?

CMS is hosting a Satellite/Webcast on Tuesday, January 31, 2006 from 1:00-4:00pm EST.

The goal of this broadcast is to provide Health Plans, Employers, Unions, and Part D Sponsors and potential applicants with an update on changes and/or revisions on the following topics:

• Overview of the Medicare Advantage Application requirements and process for the 2007 contract year for Coordinated Care Plans (CCP), Private Fee For Service (PFFS), Service Area Expansions (SAE) and Medical Savings Account (MSA)
• Overview on the Part D application process for the 2007 contract year
• New Part D sponsors seeking to offer a prescription drug benefit and existing Part D sponsors seeking to expand current service areas.
• Benefit design, enrollment, and pharmacy access requirements
• Special Needs Plans (SNP)
• Applications for employer and union direct contracts

Continue reading Want To Create A New Medicare Plan in 2007?…

Part D CREDITABLE COVERAGE DISCLOSURE TO CMS

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires entities that provide prescription drug coverage to Medicare Part D eligible individuals to disclose to CMS whether the coverage is creditable or non-creditable. CMS has issued guidance on the form, manner and timing of providing the Disclosure Notice to CMS. This Disclosure to CMS guidance is posted on the Creditable Coverage web page at http://www.cms.hhs.gov/CreditableCoverage/.

An entity is required to provide the Disclosure Notice through completion of the Disclosure Notice form on the CMS Creditable Coverage Disclosure Web Page at http://www.cms.hhs.gov/apps/ccdisclosure/default.asp unless specifically exempt as outlined in the Disclosure to CMS guidance. Additional information about creditable coverage is available on CMS’ Creditable Coverage web page at http://www.cms.hhs.gov/CreditableCoverage/.