Practice Manager Insider

New at CMS: Software for Remittances, CAP Information Posted

The Center for Medicare & Medicaid Services (CMS) has posted on its website an article explaining its new Medicare Remit Easy Print software. Practices can use this software to view and print Electronic Remittance Advice (ERA) that complies with the Health Insurance Portability and Accountability Act (HIPAA). CMS had previously announced its plans to reduce the number of Standard Paper Remittance Advices (SPRs) printed and mailed, and to increase use of the electronic remittances (ERA). To use the easy print software, practices must receive HIPAA-compliant ERAs. Contact your carrier to find out more about how to obtain the software or how to receive HIPAA-compliant ERAs.

In other CMS news, the slides and audio from a May 11 teleconference about the Competitive Acquisition Program (CAP) for Medicare Part B drugs and biologicals are  posted on the CMS website. The teleconference program was called “Ask the Contractor.”

CMS Reports Last-Minute Stampede to Join Part D

The final day of the first 6-month window to enroll in Medicare Part D was May 15, and the Centers for Medicare & Medicaid Services (CMS) estimates that well more than 1 million beneficiaries signed up during the final week. CMS is still tabulating final enrollment numbers but has processed 872,000 enrollments from the final week. Many more from what it described as the “last-minute enrollment surge” are backlogged. This includes more than 500,000 persons who signed up online since May 7 – 143,875 of them on May 15. CMS estimates that more than 90% of Medicare beneficiaries—totaling more than 38 million people—now have some sort of prescription drug coverage.

Beneficiaries may have been motivated by the 1% per month penalty to be assessed permanently on the premiums of those who put off signing up until subsequent open enrollment periods. The next such window opens on November 15 and lasts for 6 weeks.

A bipartisan group of senators is sponsoring legislation to waive that penalty for the upcoming enrollment period. CMS already has waived the penalty for eligible beneficiaries choosing the low-income plan during the year 2006. The bill also would appropriate an additional $18 million for counseling to state-based programs such as the Area Agencies on Aging and Senior Health Insurance Information Programs.

OIG: CMS Over-Reimbursing for Part B Drugs?

The Office of the Inspector General (OIG) has issued its second report this year stating that the Centers for Medicare & Medicaid Services (CMS) has been paying too much for some Part B medications—by at least $161 million during the period evaluated.

CMS appeared to dispute some of these findings in a letter appended to the OIG report. It noted that the OIG analyzed data from third-quarter 2004. By CMS analysis, more than 92% of the OIG’s estimated savings do not persist when examining data from later periods. CMS did not indicate whether it plans to act on the OIG findings.

CMS reimburses physician practices for most Part B drugs at 106% of the volume-weighted average sales price (ASP) for the code corresponding to each medication. The law requires that the OIG compare ASPs to average manufacturer prices (AMPs) in order to identify medications for which the ASP exceeds the AMP by at least 5%. For any such medications, the Department of Health and Human Services (DHHS) can reimburse based upon 103% of the AMP rather than 106% of the ASP.

The OIG analyzed ASPs and AMPs for 364 Healthcare Common Procedure Coding System (HCPCS) codes. It found that volume-weighted ASPs exceeded volume-weighted AMPs for 34 of those codes. Reimbursement based on the higher ASP amount led to CMS overpaying physician practices by $161 million, according to the OIG. The amount of overpayment rose when the OIG considered its earlier finding that CMS is miscalculating the ASP.

CAP Update: Enroll Until June 2; Join a Teleconference Tomorrow

Practices have from now until June 2 to enroll in Medicare’s Competitive Acquisition Program (CAP). Enrollment opened on May 8. The CAP is a voluntary program that offers physicians the option of obtaining Part B drugs from vendors selected in a competitive bidding process, rather than buying and billing these drugs under the average sales price (ASP) system. The first CAP period covers July 1 through December 31, 2006. Click here for the physician election form to sign up for the CAP. The completed and signed form must be mailed to your local carrier and postmarked on or before June 2, 2006.

The Centers for Medicare & Medicaid Services (CMS) and Noridian Administrative Services (NAS) will host an “Ask the Contractor” teleconference tomorrow offering physicians and their staff an opportunity to learn more about the CAP.

Call details:

      Date: Thursday, May 11, 2006, 1:00-2:30 p.m. EST
      Title: Ask the Contractor Teleconference for CAP
      Call in Number: 1-866-216-6835
      Access Code: 329694

Please dial in 5 minutes prior to conference start time. Enter your access code, followed by the pound (#) sign. Your line will be placed on hold with music until conference start.

CMS chose one vendor to serve the entire country for 2006. BioScrip will supply about 180 drugs to physician offices. Many are used in oncology practices; click here for this list. The vendor pick was announced April 21.

CMS Q2 Part B ASPs: The Cancer-Specific Changes

The Association of Community Cancer Centers has posted a comparison of first–quarter and second–quarter average sales price (ASP) for 78 commonly used anti-cancer and supportive care drug HCPCS codes.

Medicare reimbursement fell by a median of 2.6% for 40% of these agents from Q1 to Q2. It stayed the same or rose for the remaining 60%, for a median increase of 1.5%. Some of the largest differences were: bleomycin (J9040), from $44.939 to $24.592; vinorelbine tartrate (J9390), from $38.351 to $22.254; and ifosfamide (J9208), from $33.563 to $54.710.

Two Patient Assistance Programs for Part D Enrollees Pass Muster with OIG

This is good news for your patients who are Medicare Part D beneficiaries receiving Schering’s cancer medications through the pharma’s patient assistance program (PAP) called Schering-Plough: Commitment to Care. This PAP was one of the 2 Schering programs evaluated by the Office of the Inspector General (OIG). The other, called SP-Cares, includes most of Schering’s other medications.

In light of this news, GlaxoSmithKline announced plans to request the OIG’s opinion about its proposed PAPs for Part D enrollees. It also reversed plans to bar Part D eligible patients from its PAP programs after May 15, the deadline to sign up for Part D. These actions affect the firms’ PAPs for oncology and non-oncology medications.

The OIG opinion is noteworthy on a broader level because it clarifies how PAPs that include Part D enrollees can avoid conflict with the federal anti-kickback laws. The Office of the Inspector General (OIG) issued a bulletin last fall describing how PAPs might violate the federal anti-kickback statute. The bulletin was not intended to kill PAPs; in fact, it set out guidelines for how to reduce risk of breaching anti-kickback law while running a PAP that includes Part D enrollees. But some pharmas reacted by deciding to close or restrict access to their PAPs after May 15, the deadline to sign up for Medicare Part D.  This is what GlaxoSmithKline had planned to do until the OIG released its favorable opnion about the Schering PAPs.

The Senate Finance Committee wrote to the OIG on April 17, urging it to expedite responding to pharmas’ questions about whether individual PAPs comply with the law. The next day, OIG issued a favorable advisory opinion about the 2 Schering-Plough PAPs.