The following Medicare information and resources are available to assist you in complying with reimbursement regulations:
Medicare Part D
These resources will help the rheumatologist navigate Medicare Part D.
Frequently Asked Questions
Is there a place where I can find out what procedures and laboratory tests are covered by Medicare?
Each state has a Medicare Carrier (MC) that administers the Medicare plan for that state. Each MC has a website; a complete list of these can be found at http://www.cms.hhs.gov/mcd/index_lmrp_bystate.asp. Each carrier is listed by state. Scroll down until you find your state. If you click on the block with your carrier you will see all of their Local Carrier Determinations (LCD).
The section for Final policies covers all the current payment and coverage rules for that MC. It is in alphabetical order and usually by procedure, major drugs, and other key words. While most major topics are included here you might have to do a keyword search for lesser procedures. There is also a Draft policy section that covers proposed LCDs, which you can review. During their comment period, these draft policies are open to comment and you have the opportunity to make suggestions and recommendations on them.
Medicare carriers communicate many of their medical policy changes via newsletter so it is imperative that your practice keeps current on this literature. They will also refer you to a certain newsletter if you call to ask about a policy so it is also important to keep these in order and accessible.
My practice is receiving denials for salsalate and choline magnesium trisalicyalate as "not under coverage" for Medicare patients. Is this because they haven't been studied in the FDA era like nonColcrys cochicine, or is there another reason?
CMS has made the move to require their Part D plans to cover only medications that are listed in the Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations - this is an FDA publication. When I've searched the Orange Book (electronic and hardcopy) for both salsalate and choline magnesium trisalicyalate they are not included, thus CMS mandates that they not be covered.
The Food and Drug Administration (FDA) is the regulatory agency which determines approval for all prescription medications. The Orange Book is a publication of the FDA which lists all drugs that have FDA approval. At the start of plan year 2008, CMS removed from its formulary files all of those medications which do not appear in the Orange Book.
More than 1,500 drugs were deleted by CMS from its FRF, going from 7,100 drugs to 5,500 drugs. In response, Part D plans have dropped many drugs from their formularies from 2007 to 2008. CMS has not made any coverage determinations on these medications however, and has not determined that these medications are not Part D drugs. Plans retain the ability to decide on coverage for the deleted drugs. Many medications which continue in use today pre-date the 1962 FDA requirement for proof of safety and efficacy. Prior to this, prescription drugs were approved based solely on safety, according to the Federal Food, Drug, and Cosmetic Act of 1938. These earlier medications are not included in the Orange Book and were therefore deleted from the FRF.
How can you opt out of Medicare?
A physician or practitioner who has signed an agreement to participate in Medicare may opt out by filing an affidavit that meets the criteria and which is received by the carrier at least 30 days before the first day of the next calendar quarter showing an effective date of the first day of that quarter. Their participation agreement will terminate at that time. They may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit. Non-participating physicians and practitioners may opt out at any time.
Once a provider opts out of Medicare, to stay a non-participating provider you must opt out every two years.
If you've decided to opt out of Medicare, you'll need to take the following steps:
- Notify your patients, colleagues and others. The first step in the opt-out process is to notify your Medicare patients and others of your intent. Send a letter to your patients explaining what opting out means, your reasons for doing so and their options for staying with the practice or finding a new physician. The letter should be sent in advance of opting out so patients have time to make alternative arrangements if needed.
- File an affidavit with Medicare. The next step is to notify Medicare. You'll need to file an affidavit with each Medicare carrier that has jurisdiction over claims that you have filed or that would have jurisdiction over your claims had you not chosen to opt out. The Medicare carrier must receive the affidavit at least 30 days before the first day of the calendar quarter, i.e., Jan. 1, April 1, July 1 and Oct. 1, following your opt-out date and within 10 days of entering into your first private contract.
- Privately contract with the Medicare patients you continue to care for. Medicare patients who elect to receive care from you other than on an urgent care or emergency basis must sign a private contract before you can treat them. The only exception is for Medicare patients who need emergency or urgent care services. In this situation, append modifier-GJ—"'Opt out' physician or practitioner emergency or urgent service"—to any codes you are billing to indicate the service was provided by an opt-out physician providing emergency or urgent care.
- Initiate appropriate office procedures. Once you've executed your affidavit(s) and private contracts, you need to establish office procedures to ensure that you comply with the opt-out rules. For example, you will need to implement procedures to identify Medicare patients and ensure that they are notified of the opt-out decision as well as remind them of payment arrangements when making appointments.
- Mark your calendar to renew your opt-out status. Your final step is to mark your calendar for reminder to send in a new affidavit every two years to maintain your opt-out status. Failure to renew your opt-out affidavit will mean you are entering into private contracts with patients without Medicare's consent. If, after two years of opting out, you choose to re-enroll in Medicare, you will need to complete a new Medicare physician enrollment form, just as you would if you were new to the program.
Can you bill the patient for cancellations?
Yes the physician can charge for this as long as all patients are subject to the cancellation fee. Also the notice should be displayed prominently in the office where patients can see it.
Does Medicare cover and reimburse for ENBREL used for ongoing therapy?
Congress recently passed a Medicare law, which may allow for reimbursements of self-injectable treatments for some Medicare patients with moderately to severely active rheumatoid arthritis, psoriasis, psoriatic arthritis, and ankylosing spondylitis.
Call 1-888-4ENBREL (1-888-436-2735) for information regarding coverage for ENBREL under Medicare Part D.