Part D or Not to Part D: That is the Question for Infusion Providers
By
Dave Grady
, Spotted Dog Consulting
While retail pharmacies have been forced to embrace the Medicare Part D drug benefit and its rocky implementation, infusion pharmacies as a group, have been reluctant to get on board.
For infusion providers, Part D is a different animal altogether and requires both software and a mindset which accommodates point of sale even though the patient care issues still involves a longer-term continuum. Should infusion providers play in both worlds?
The world of the retail drug benefit involves the classic count, pour, lick and stick process; it includes one time patient consults; it means using software that can conduct “point-of-sale” functions such as E1 verification and transmitting claims via NCPDP format; it requires asking the patient for a co-pay. So why should infusion providers be a part of this world?
Perhaps the most important impetus for many infusion pharmacies is the change in the way we handle patients who have “dual eligibility” or are covered by both Medicare and Medicaid programs. Prior to January 1, 2006, most infusion therapies were not covered by Medicare so if a patient had dual eligibility, you could assume, through a process of billing for denials or educating your Medicaid program, the drugs, supplies and maybe services would be covered by the state’s Medicaid program. With the implementation of Part D, the drug was no longer covered by the Medicaid program. To retain your existing “dual eligible” patients and to take on new ones, providers had to acknowledge that Part D was a reality.
Depending on the state, there may be reimbursement issues that make taking dual eligible patients problematic or even undesirable. If per diems are not recognized, supplies reimbursed poorly and the cost of your services ignored, it may be a good time to evaluate the worth of participating in your state’s Medicaid program. However, it seems the vast majority of providers want to continue to take on Medicaid patients; which means becoming involved directly or indirectly in Part D.
Direct involvement entails signing up with the various Part D Plans (PDPs) operating in your state and then billing directly to those plans whenever dispensing Part D eligible medications. Indirect involvement entails having an agreement with another pharmacy that will “dispense” and bill for the drug, but turn the compounding, supply, and service components over to you, the infusion provider. The latter arrangement allows the infusion pharmacy to concentrate on providing the traditional infusion services and not become involved with aspects of dispensing and billing for which it may not be familiar or want to offer. However, this type of arrangement also introduces yet another layer to the process and requires a bit more work and organization on the provider’s part.
With the advent of the Part D benefit, many infusion providers have decided to branch out and participate in Part D. In addition to retaining the “dual eligible” patients, provider can also more effectively serve the Medicare beneficiaries who either have secondary insurances which will pay for supplies, pumps and services (S codes) or who are willing to pay out of pocket for those same items. Not so surprisingly, there are a growing number of Medicare patients who will opt to pay cash for non-covered items and services when confronted with not so appealing alternatives such as long term hospitalization, two or three daily visits to the ER or a skilled nursing facility admission.
Adjudicating NCPDP claims on-line may be the most important part of participating with the PDPs. Without a software system which can convert your claims or without knowledgeable and trained staff who can submit NCPDP transactions (including eligibility verification, drug formulary status and claims), it will be tough to participate effectively. These two factors are a must for success in the Part D world.
After years of trying to separate ourselves from “retail pharmacy,” it might seem that infusion providers are taking a step in the wrong direction by participating in a system that rewards discounted drug reimbursement and essentially ignores the service component of infusion therapy. For infusion providers, Part D participation may only be a short term answer to a much more fundamental question: when will we be treated like other medical service providers?
There may be hope. Federal legislation has recently been introduced in the form of H.R. 5791 (The Medicare Home Infusion Consolidated Coverage Act of 2006) requesting that the Medicare Part B benefit be expanded to included coverage for home infusion therapy (see the National Home Infusion Associations’ website at www.nhianet.org for more detailed information about this legislation). Obviously this is great news and major step in the right direction. Infusion providers and those connected to the industry should be asking our Senators and Congress folks to support this bill.
However, passing and implementing law can take some time, so until it is passed, the question infusion providers must answer is this: do I or don’t I “Part D’?
Factors for Effective Part D Participation:
- Software that will easily submit NCPDP transactions
- Staff knowledgeable about NCPDP transactions
- Educate yourself about the Part D benefit including co-pays and the infamous “donut hole”
- Excellent communication between Pharmacy and Billing Departments
- Patience and diligence in securing Part D contracts from PDPs
- Learn to effectively communicate to your customers and patients how Part D benefits and infusion therapy works (or doesn’t work in some cases).