From The College March 2006

The complete newsletter is available in PDF format, below.

Featured Article

Part D Problems May Be Resolved

Pre-Authorization Not the Only Option
Media reports in the first months of 2006 have chronicled several serious problems with the implementation of Medicare Part D, both for patients and for physicians. The practice advocacy department at the ACR has received hundreds of calls from members across the country seeking assistance on how to manage having to obtain authorizations for necessary rheumatology medications. ACR staff have researched solutions, and have identified steps you can take to make it less burdensome to serve these patients.

A Key Problem: Oral Methotrexate
The main drug rheumatologists are experiencing difficulty with is oral methotrexate but we have also received word that physicians are being required to obtain pre-authorizations on drugs such as folic acid, prednisone and vitamin D. Complaints include spending 60 to 90 minutes on phone calls to obtain an authorization, to being told the drug is covered under Medicare Part B.

The Solution
CMS has created a system to simplify the process and access to Part D drugs. They now recommend that physicians clearly differentiate the drugs that are covered under Part B from drugs which may qualify as Part D.

CMS recommends that the prescription should now be written with the diagnosis and indication as well as the statement of status as Part B or Part D. As an example, CMS instructed that methotrexate for rheumatoid arthritis should be specified on the prescription, and the designation Part D should be added to the prescription. CMS has assured the ACR that this solution is not in any violation of HIPAA regulations.

Importantly, CMS states that this is not a guaranteed solution but this recommended process may help pharmacists respond more readily to additional information to support Part D or Part B coverage.
CMS has provided a Web link of certain oral and immunosuppressive drugs that are covered under Part B, www.cms.hhs.gov/pharmacy/downloads/partsbdcoverageissues.pdf. This list is not complete, but may be of assistance when physicians are writing prescriptions for their patients.

ACR’s Concerns
The ACR is confident that CMS is making a step in the right direction but has concerns regarding whether the Prescription Drug Plans are willing to make this a workable solution. CMS assured us that they would also be sending all PDP’s similar correspondence to help make this solution successful.
If members have followed CMS’s recommendations and are still having difficulty, please contact the ACR practice advocacy department, and send CMS your complaints with the specifics on what drug and what PDP you are dealing with to PRIT@cms.hhs.gov.

ACR wants members to be aware that we have been diligently working and will continue to work on this issue through frequent communications with CMS, members, and PDPs. The practice advocacy department will closely monitor Medicare Part D and any new issues that may arise. Members will be notified as soon as resolution is found.

The Practice Advocacy Department, along with the Regional Advisory Council, is available to all members for assistance on this issue or any coding and reimbursement issues. If you have any questions or concerns please contact Sarah-Jane Bennett, Senior Director, Practice Advocacy, in the ACR office at (404) 633-3777 (ext. 818). Coding specialists Antanya Chung and Melesia Collins are also available for member support; they can be reached at (404) 633-3777 extensions 819 and 820.