By Kevin Schweers
NCPA is providing feedback and suggestions to Centers for Medicare & Medicaid (CMS) officials grappling with unintended consequences impacting patient care in hospice settings stemming from a new policy the agency implemented May 1, 2014.
Patients and community pharmacists are sometimes caught in the middle as hospice facilities and Medicare Part D drug plans (or pharmacy benefit managers) debate which one of them is responsible for paying the cost of certain prescription drugs. The new CMS policy envisions hospice paying for drugs directly related to the condition requiring hospice care and Part D plans handling the rest. However the occasional gray area between the two has prompted some confusion and the potential for delays to patient care.
The Center for Medicare Advocacy posted on its website a fact sheet on this issue, including a hypothetical example illustrating the problem:
Mr. B. was 83 years old. He was quite healthy and independent, living an active life with the help of a few medications, including one to control his blood pressure. After experiencing some uncomfortable indigestion, he went to his physician. Sadly, he was diagnosed with metastatic pancreatic cancer and given a limited life expectancy. He elected the hospice benefit. Under this new protocol, when his wife goes to the pharmacy to re-fill his life sustaining blood pressure medication to prevent a stroke, the request for payment will be automatically denied. This is despite the fact that Mr. B. will be at high risk for a stroke without the medication. Mrs. B. will have to contact the insurance company to appeal the denial. The insurance company may not speak to Mrs. B. because she is not an “appointed representative.” Mr. B. may not feel well enough to call or to complete the required paperwork. If Mr. B is up to negotiating the appeal process, the insurance company should then call Mr. B.’s doctor who may or may not agree to fill out the pre-authorization form. If Mr. B’s doctor does not fill out the form, the insurance company may or may not contact the hospice provider. In the meantime, due to a protocol designed to save the insurance company money, Mr. B. may have a stroke.
This issue has gained the interest of Members of Congress (75 Senators, 202 Representatives) and the Medicare Payment Advisory Commission (MedPAC), both of which have sent letters to CMS asking the agency to suspend the current Part D prior authorization process for hospice beneficiaries.
In addition, NCPA responded to a request for comments from CMS on coordination of benefits process and appeals for Part D payment for drugs while beneficiaries are under a hospice election.
NCPA is urging CMS to take actions to improve the information flow related to hospice elections; increase accountability associated with conveying this information to vested parties; identify an enforcement contact if a party fails to cooperate; and protect against unfair audit practices.
NCPA will continue to closely follow this issue, and provide members with timely updates, as CMS has indicated additional clarification guidance is forthcoming.