Is a new wave of patients unwittingly “signing up” for Express Scripts mail order? The giant pharmacy benefit manager (PBM) is reportedly expanding a program in which patients are enrolled into mail order unless they call the PBM to affirmatively opt out.
Archive for September, 2010
Tags: pharmacy benefit managers
Tags: durable medical equipment
Most independent community pharmacies provide durable medical equipment (DME), like diabetes testing supplies, to meet essential health needs while partially offsetting diminishing prescription drug reimbursement. About one out of every three pharmacies that offer these test kits also stock therapeutic shoes for diabetics and these pharmacies may soon face more demanding audits by Medicare contractors.
For years, the Centers for Medicare & Medicaid Services (CMS) appeared to consider a signed certifying statement by a physician as sufficient evidence to support a claim for reimbursement for therapeutic shoes.
More recently, NCPA members noticed that Medicare Administrative Contractors (MACs) seemingly altered their auditing practices and began to seek recoupment of reimbursements, even in instances in which the supplier produced a signed certifying physician statement. Instead the MACs began demanding that the pharmacy produce medical records from the physician to match the information on the certifying statement or written order.
NCPA is asking CMS to reevaluate this situation, which has the potential to undermine patient access to these products as pharmacies choose to stop offering them because of the burdensome auditing requirements that they now face.
What follows are excerpts from a letter NCPA sent to the agency:
“Requiring suppliers, such as independent community pharmacies, to obtain medical records from physicians imposes a significant administrative burden on small business suppliers, as well as physicians. Physicians now want to know why their signature on the certifying statement is no longer sufficient and are resistant to the extra effort required to meet supplier requests for physician records. Given the administrative burdens, these physicians may be reticent to provide future referrals to the suppliers.
“Presently, some suppliers have indicated that the new administrative burden is too much for them and that they may decide to stop providing therapeutic shoes. As a result, patients are either forced to obtain their therapeutic shoes from other suppliers, or simply refrain from obtaining the shoes. In the latter situation, in the end, all too often these fragile, high risk patients go from needing therapeutic shoes to developing even more serious lower extremity complications.
“The bottom line is that suppliers are put in the untenable position of being asked to provide care without knowing whether the physician’s records provide adequate documentation or whether the supplier will be able to obtain those records. … We urge CMS to revert to its original enforcement policy of accepting the signed and dated certifying statement as sufficient documentation for the provision of therapeutic shoes and inserts. Without this change in policy, many suppliers will cease to provide therapeutic shoes, patients will lose access to those necessary medical supplies and patient diabetic health outcomes will suffer.”
New opportunities for community pharmacists to expand the diabetes care services that they provide offer a win-win-win: healthier patients; lower costs for health care payers; and a new revenue source for local pharmacists facing declining prescription drug reimbursement.
By John Coster, RPh., Ph.D.
As lawmakers prepare to return to Washington after August recess, many utilized the summer to meet with pharmacists and constituents at their local pharmacy.
By John Coster, RPh., Ph.D.
Many community pharmacists are reporting a steep reduction in reimbursement for generic drugs provided to military service members, dependents and retirees covered under the Pentagon’s TRICARE program.