I Don’t Take Third-Parties…

By: IACP’s Executive Vice President & CEO David Miller, RPh

That phrase starts a conversation I hear from IACP members several times every day.

It’s usually followed by that language equivalent of squealing tires and a thump as everything comes to a screeching halt – the word “but”. And whatever follows next is a problem with a third-party of some sort.

Last week, one of our members called pretty incensed that IACP is even bothering with third-parties. “It will be the ruin of compounding! They’ll strip us to the bare bones! We should fight them!”

You see, the thing is, every compounder is involved in third-party reimbursement. Whether you have a contract or not, whether you’re a network provider or not, and whether you only accept cash or credit cards as payment… you’re still faced with third-party rules.

But (tire screech, thump) you’re thinking… that’s not the case for MY pharmacy.

Of course it is. Anytime you provide a patient with a completed universal claim form to submit to their insurance company, you’re dealing with a third-party. When a problem arises with the patient’s reimbursement, who gets called? You do. And our first responsibility is to our patients. So… we get sucked into dealing with third-parties.

The past month has been an ongoing hassle with Medco and their implementation of a new NCPDP claims standard (called Version D.0) which goes into effect January 1, 2012. Medco decided to adopt the new standard in July.

Good for them! Of course, it would have been nice if they’d TOLD people they were doing it six months early. You know, people like the pharmacies who complete claim forms, people like the patients who have prescription drug coverage through them, people like the employers and insurance companies that contract with them for those services.

Instead, they flipped a switch and then started denying claim forms left and right. IACP members were inundated with calls from their contracted call-center ACS. “It’s a new policy, you have to give us this” was the standard line. When pressed for a copy of the policy, things got very vague, very fast.

It took a month of work and a lot of calls but as of yesterday, Medco is immediately reverting back to the original NCPDP claims form it, and compounders “who don’t take third-parties” had been using. That one, by the way, is called Version 5.1

Good for us! Our work solved a problem and (hopefully) the harrassing phone calls will cease. Click here to take a look at our Member Center for a patient information sheet to give to your customers who’ve had their claims rejected by Medco.

Not good for us. The scheduled implementation of NCPDP Version D.0 on January 1 is part of a broader overhaul of the electronic claims processing mandated by CMS three years ago. To read about that in excruciating beaureaucratic language, click here.

These new standards, which are an outgrowth of requirements in the original HIPAA law from years ago, apply specifically to CMS funded programs. That’s Medicare and Medicaid. But… (tire squeeling screech)… pretty much every private insurance company like Blue Cross, Aetna, United Health, etc., will also implement VD.0.

At this point, we don’t know how D.0 is going to affect paper claims submitted by patients and beneficiaries who choose to use non-participating network provider physicians, hospitals, pharmacies or compounding pharmacies. That’s something IACP will continue to investigate.

In the meantime, keep this in mind. D.0 is coming. Whether you are a cash-only pharmacy or whether you accept third-parties, it’s going to have some impact on your business and your practice.

Editor’s Note: NCPA invited our friends at the  International Academy of Compounding Pharmacists (IACP) to discuss their thoughts on third party reimbursement. What follows is their account of the impact of third parties on compounding pharmacists. Learn more about compounding, third party reimbursement, and other topics important to your pharmacy at the upcoming NCPA Annual Convention and Trade Exposition, October 8-12 in Nashville.

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