October 2022 - Newsletter

Included in this newsletter




National Supplier Clearinghouse (NSC) Ends Its Contract on 11/6/22

The Centers for Medicare & Medicaid Services (CMS) has awarded a new contract for DMEPOS and Part B Pharmaceuticals. The country will be split between two contractors: Novitas Solutions and Palmetto GBA. We will update any affected policies and procedures and forms to reflect this change. Please notify your liability insurance carrier to remove NSC as a Certificate Holder and replace it with the respective contractor based on the list below:

  • Novitas Solutions – National Provider Enrollment East: Alabama, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia, Wisconsin, District of Columbia, Puerto Rico, US Virgin Islands
    Website:  https://www.novitas-solutions.com/webcenter/portal/DMEPOS

  • Palmetto GBA – National Provider Enrollment West: Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Louisiana, Minnesota, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming, American Samoa, Guam, Northern Mariana Islands

Change the Certificate Holder name and address on Liability Insurance to:

    Novitas Solutions
    2020 Technology Parkway
    Mechanicsburg, PA 17050

    Palmetto GBA
    Mail Code: AG-310
    P.O. Box 100306 Columbia, SC 29202-3306

R.J. Hedges & Associates Brokerage and Valuation Services

R.J. Hedges & Associates can also provide our compliance customers with assistance for Business & Pharmacy Valuations, Business Brokerage (Acquisitions & Mergers), Representation during acquisition sales, and Business Management Consulting. Please talk to your Project Manager to get more information.

CMS Sets Patients Deductible for 2023

CMS has released the new Part B beneficiary deductible for 2023. Medicare Part B beneficiaries will pay the first $226 in 2023, a decrease of $7 from the annual deductible of $233 in 2022.

If your pharmacy or DME facility bills immediately after dispensing, the staff will need to know what the deductible is in order to collect the full, authorized amount. The deductible is mandatory as part of the Medicare Part B patient agreement.  The first claims received will have the deductible applied. It is always easier to return money than to try and get it after the claim has been paid.

Medicare Part B Billing Concerns

Recovery Audit Contractor (RAC) audit errors occurring this year. The most common reason for an error followed by a denial of reimbursement comes down to incorrect Modifiers and Date of Service. Pharmacy software companies appear to have no place to record the correct modifiers. In some cases, the modifier is assigned without the knowledge of the pharmacy. In addition, if the incorrect dispensing quantity or date of service is entered, there is a warning pop-up.

Most pharmacists and technicians do not understand the meaning of a billing override. Some electronic billing software will have an “override” when something is amiss, but a simple keystroke, such as F7, allows the claim to proceed to adjudication. The billing override informs CMS that all of the documentation for exceeding the required dispensing is correct. The adjudication of Part B claims through an electronic software system only validates the data entered meets the valid format for a CMS Part B data set.

Every Part B product, except for immunizations, has a specific Detailed Product Description (DPD) that provides everything the data entry person needs to prevent most of the denials. In almost every case, the person who enters the initial prescription into the pharmacy software is unaware of the requirements of the Local Coverage Determinations (LCD). The more we dig through this issue, the worse it gets. The Detailed Product Descriptions are found in the DMEPOS Compliance Program, Section 2A Supplement – Dispensing Documents and in Pharmacy Compliance, Chapter 3, Pharmacy Operations, Item 1e, Medicare Part B Drugs Documentation.

DMEPOS facilities and pharmacies that direct bill and use a billing service do not seem to have these errors.

Compliance Portal® Spotlight – DEA Compliance – Drug Diversion Changes

In conjunction with the US Department of Health and Human Services and the CDC, DEA has changed the C-II documentation requirements. The main change revolves around Morphine Milligram Equivalents (MME). There are physician requirements concerning treatment goals and plans. When a patient is prescribed 50 MME or greater, physicians must assess and reassess individual benefits and risks when increasing the dosage to ≥50 MME/day, especially in combination with a benzodiazepine. A copy of the treatment plan must be available starting at 50 MME; if the dosage is 90 MMEs or greater, the treatment plan must be sent to the pharmacist and maintained with the prescription record. The pharmacist has a Corresponding Responsibility to ensure the dosage requirements are valid for the patient throughout the treatment plan. In addition, Naloxone should be considered for the patient.

Patients who have chronic pain, severe pain, or are in hospice routinely will exceed 90 MME. The pharmacist should consult the physician on the treatment plan in these cases. This conversation must be added to the patient's prescription profile for future reference.

The Due Diligence Policy and Procedure has been updated with these requirements and is found in the Compliance Portal®, DEA Compliance, Item # 3, Drug Diversion Due Diligence.  This policy has doubled in size and every pharmacy owner, pharmacist-in-charge, and pharmacist must read this policy. DEA has quietly announced these changes' enforcement on July 1, 2022. DEA has restarted its on-site inspections, including reviewing the state's Prescription Drug Monitoring Program (PDMP). DEA appears to be very aggressive with these inspections.

TriCare Beneficiaries Forced to Move to Mandatory Mail Order or Chain Pharmacies Only

TriCare is forcing all Department of Defense (DOD) active-duty personnel and DOD retirees to move to mandatory Express Script Mail Order or go to a national chain. There is a lot of pressure on DOD to return independent pharmacies as a participating pharmacy.

Personal Note from Jeff:
My local pharmacy ran his generics as a cash price. Except for one prescription, the cash price was cheaper than the current co-pay. You can offer this to your TriCare patients and there are no DIR fees for cash sales.

Upcoming Changes to USP General Chapter <795> and <797>

United States Pharmacopeia (USP) has received feedback from its stakeholders to ensure broad perspectives were included in the updated standards with a continuing focus on patient safety and access to quality medicines. The revisions will be published in the USP-NF and USP Compounding Compendium on November 1, 2022.

Enforcement Actions

Updated Forms

  • HIPPA Compliance

    • Breach Response Checklist

    • Unsecured PHI Breach Reporting Checklist

    • PotentialBreachAnalysisEvaluation

  • DMEPOS Compliance

    • Ankle-Foot/Knee-Ankle-Foot Orthosis

    • Commodes

    • Glucose Monitors & Supplies

    • High Frequency Chest Wall Oscillation Devices

    • Knee Orthosis

    • Manual Wheelchair Bases, Seating, & Options/Accessories

    • Nebulizers and Supplies

    • Orthopedic Footwear

    • Ostomy Supplies

    • Pneumatic Compression Device

    • Power Mobility Devices

    • Wheelchair Options and Accessories

    • WheelchairSeating

  • Immunization Compliance

    • Notification of Vaccination Letter

    • VaccineCoordinatorDesignation

Updated Policies & Procedures

  • Compounding Compliance

    • Facilities and Engineering Controls Policy and Procedure

  • Pharmacy Compliance

    • Remote Medication Order Processing Policy and Procedure (NEW)