Medicare Reform Advisor, April 13, 2004
Medicare Reform Advisor, April 13, 2004
© 2004 HCPro, Inc.
Managed care reaction affects entire industry
Managed care will return to fee-for-service plans with more emphasis on disease management and identifying risk, a focus group of managed-care analysts told Medicare Reform Advisor in March. Here are four examples of what's already happening:
There are trade-offs, said analyst Peter Volk, who is based in New York City. "You'll see inpatient deductibles and higher office copays, higher service copays. But they'll be new benefit categories, such as an injectable medications benefit."
Expect inpatient out-of-pocket costs to hit $1,250 per admission. There will also be benefit limits on services such as physical therapy, durable medical equipment, chiropractic care, and private duty nursing.
CMS covers three more injectables, four devices
These payments took effect April 1, according to a release from the Centers for Medicare and Medicaid Services (CMS).
Coverage set for GERD, prostate devices
This update from CMS also covers billing and payment issues affecting intensity modulated radiation therapy and brachytherapy devices used in cancer treatment. Go to www.cms.hhs.gov/manuals to read the complete update. Look for program transmital 132.
Poll: Officials to watch P&T committee grants
Injectable use changing rapidly with Medicare reform Infusion costs big in specialty pharmacy dealings "Providers will need to know their infusion costs in order to negotiate adequate infusion fees that include cost of mixing, inventory, wastage, etc.," says Sigrid Schreiner, MHA, CMPE, director of reimbursement at the Lash Group, a Charlotte, NC-based consulting firm for physicians and pharmaceutical companies.
Injectable use changing rapidly with Medicare reform
Infusion costs big in specialty pharmacy dealings
"Providers will need to know their infusion costs in order to negotiate adequate infusion fees that include cost of mixing, inventory, wastage, etc.," says Sigrid Schreiner, MHA, CMPE, director of reimbursement at the Lash Group, a Charlotte, NC-based consulting firm for physicians and pharmaceutical companies.
CASE: A lesson in how all e-mail is discoverable
Dr. Brown has been a consultant for a prominent drug company for three years. E-mails circulated between two drug-company employees about Brown's work. The following is an excerpt from one e-mail exchange:
Employee A: "We have paid $500,000 over the first few years to Dr. Brown, but he hasn't produced much scientifically."
"Make sure the consultants do something," says Elizabeth Carder-Thompson, a law partner at Reed Smith in Washington, DC. "Have a contract and identify a legitimate need. You can't go out and hire every oncologist to tell you what you need. If you hire too many, the government will wonder what you're paying for."
Martin Doyle, a Medicare-law consultant based in Greenwich, CT, says drug companies must use people who have clinical backgrounds and jobs to select these consultants. That didn't happen in the Brown case. "You can use sales and marketing staff, too, but they shouldn't lead the charge," says Doyle. "Hire only the number of consultants you will legitimately need and use."
Ohio hospital allowed to charge free clinic for drug acquisition
The agreement grew out of the clinic's ongoing financial dilemma: It had to pay a local pharmacy more than Dunlap did for drugs. It paid the pharmacy at each drug's average wholesale price (AWP), plus a dispensing fee.
Enter Dunlap. The nonprofit purchases pharmaceuticals through Amerinet, a hospital-purchasing group. Through this deal, it pays a lower price than is currently available to the free clinic. So Dunlap's Vice President Judy Erb asked the FTC whether the hospital could legally purchase drugs and send them to the clinic's volunteer physicians to dispense to patients. The kicker: Could the hospital charge the clinic a small fee to cover its costs?
The FTC said yes. The Non-Profit Institutions Act of 1938 covers transfers of this nature, according to Jeffrey Brennan, the FTC's assistant director of healthcare services and products. Brennan says the receiving institution, in this case the clinic, must dispense the medicine for its own use, for its patients.
According to Brennan, nonprofit institutions that purchase pharmaceuticals may transfer them to another nonprofit and charge them the following:
This ruling applies only to Dunlap's case, Brennan says, but other hospitals can get a sense of the requirements and apply them. He advises hospitals and clinics to seek FTC opinions before moving forward, since there are different factors at play in each case.
Case in point, a hospital cannot charge overhead expenses that it incurs without regard to the transfer, Brennan told Dunlap in the FTC opinion.
The FTC receives about two to three requests for opinions a year related to the Non-Profit Institutions Act.
But, thanks to the Medicare reform law, AWP is going away. Some pharmacy analysts are interested to see whether the changes in Medicare pricing and reimbursement for drugs force physician clinics and hospitals such as Dunlap to reevaluate these types of relationships.
Editor's note: The Viola Startzman Free Clinic is funded entirely by donations, grants, and unpaid services of volunteer physicians.
NEED TO CONTACT US?
- Differentiate between types of wound debridement
- Complications from immobility by body system
- OB services: Coding inside and outside of the package
- Don’t forget the three checks in medication administration
- Note similarities and differences between HCPCS, CPT® codes
- What does case-mix index mean to you?
- Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines
- ICD-10 tip: Coding for infectious and parasitic diseases
- ICD-10-CM coma, stroke codes require more specific documentation
- Fracture coding in ICD-10-CM requires greater specificity
- Initiative launched to prevent physician, medical trainee suicides
- I Have to Learn This, Too?
- How surviving a disaster changes the disaster plan
- Gap analysis: Three big issues
- Ensure compliance when reporting cirrhosis and alcoholic hepatitis with an MCC
- CMS seeks comment on Medicaid HCBS
- CMS launches new online tool to make Quality Payment Program easier for clinicians
- Assessing weapons in your healthcare facility
- Analyzing nurse staffing: Understanding FTEs
- A clarification on billing for CAH swing bed services