Today my inbox has been flooded with emails about the proposed Department of Public Welfare reimbursement cuts.
After reading through the emails, I realized just how detrimental this will be to our independent pharmacies in Pennsylvania.
According to the Pennsylvania Pharmacists Association, the proposed regulations would cut at least $64 million from community pharmacies within our state. You may be asking how this can be so? Well in the proposed regulations, Medicaid prescriptions reimbursements would be cut by 50%. So every Medicaid prescription that you process, saying that it is a normal drug, you will only be getting back $2, and then if you process a compounded drug, well that will get you $3.
The average cost to a pharmacy to dispense a medication is $12, and that does not include the cost of the drug.
Okay now that I have depressed all of my pharmacy friends in Pennsylvania, let me give you a battle plan to help stop this.
You need to make some very important phone calls. Call your representative and senator as well as the governor’s office. You must alert them that this is going to make a huge economic impact to our pharmacies. Tell them that there are other options, like generic dispensing.
Here are some talking points from PPA to help you out.
- "Reimbursement levels in Pennsylvania are already extremely low and significant cuts will put Pennsylvania among the lowest 50 states."
- "It is already common knowledge that the cost to the pharmacy for purchasing, filling, and distributing some prescriptions in MA programs costs more than the reimbursement. Further cuts would be devastating to pharmacies in Pennsylvania and would eventually threaten the existence of com-munity pharmacy, thus limiting access."
- "Pharmacies rely on what little reimbursement they receive from Medicaid and this helps them keep their doors open. Cutting reimbursement rates will force them to close their doors and in turn, family sustaining jobs will be lost at a time where we can't afford to lose any more."
- "Community pharmacies going out of business will decrease access to prescription medications which will result in greater overall health care costs."
- "Cuts at the Medicaid level will set a scary precedent that many managed care organizations will soon follow. Thus, the same negative effects will be felt throughout the entire state; threatening Pennsylvania's entire health care system."
Medicare Audits are on the rise and pharmacists have concerns. So many people have been calling asking “why am I getting audited?” “Do I really need to bother feeling out the audit?” “ It is just one payment I will loss so it’s not that big of a deal, right?”
Well let us examine first what exactly a Medicare Audit is. An audit performed by CMS is to “identify improper Medicare payments and fight fraud, waste and abuse in the Medicare program.”
According to CMS the purpose of RAC audits (Recovery Audit Contractors) are to “identify improper payments made on claims of health care services provided to Medicare beneficiaries.”
With CMS performing these RAC audits they have been able to identify:
- $900 million in overpayments (which has been returned to the Medicare Trust Fund between 2005 and 2008)
- Almost $38 million in underpayments, which was then returned to health care providers (this could be you!)
When you get a RAC audit, it is extremely important that you fill out the paper work completely as asked.
Here are some key facts you need to know about RAC audits:
- You have 30 days from the date the letter was written to return the audit back to CMS with the proper documentation
- You only have 1 chance to send in the supporting documents for this audit. So make sure you gather everything they ask for, especially the physician’s clinical/progress notes
- If you don’t return the entire patient package requested in the audit you will:
- Loss that claims reimbursement
- Set yourself up for more RAC audits
- Potentially go to a 100% Pre-Payment Audit (send all required documentation in before Medicare will reimburse)
- If you lose a RAC audit, you can file a Redetermination form with all supporting documentation to be reconsidered for reimbursement
So it is up to you on what you want to do when you recieve a RAC audit. However, in my opion if you don't take auction, you are setting yourself up for unneeded stress.
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Recently we have been getting a lot of questions about what the documentation requirements are for diabetic supplies to satisfy Medicare audits.
Here are some key things Jeff has found:
- Refills have to be documented whether the refill request was called in or the request was made in person
- Authorized Representative: must provide signature, printed name, relationship to patient, and indicate the patient was either physically or mentally unable to sign for the product
- Must record: Make; Model; Serial Number; Lot Number; and Expiration Date of product dispensed
- Prescriptions are only valid if the patient has been seen by their physician within the preceding six months
- If physician orders are greater that the allowable, the prescription is only valid for six months. In addition, a CMN or Detailed Written Order must be signed by the physician prior to billing Medicare
- If the pharmacy uses eRx Network (Allwin) or OmniSys, the patient must pick up the Rx on the date the label is printed. If the Rx is run and label printed on Monday, but the patient does not come in until Tuesday, CMS will pull back the reimbursement because the date of service started prior to the actual pickup date.
- Diabetic Testing logs:
- Must be obtained for all Medicare patients
- Patient testing must match the prescription
- If patient is non-compliant with physician’s order, fill the Rx for the actual usage and zero out the refills. Patient must see physician to seek a new prescription
