*** UPDATE ***

I recently spoke with an individual from the International Academy of Pain Management regarding the previously discussed CMS Medicare billing issue. From this discussion, it has been suggested that CMS acknowledges that pharmacies billing Medicare for implanted drug pump medication provided “incident to” a physician service is “questionable” practice. It was also suggested that this issue will most likely come to a head in the coming months.

One compounding pharmacy in particular who submits billing has admitted to this IACP source that their organization is aggressively trying to grow business in an attempt to gain market share before governmental agencies possibly ban this act – which is rumored to be happening in the next six months or so.

Please be clear that Hartley Medical is not stating that what these pharmacies are doing is illegal – but we are stating that their actions are questionable. We also cannot be 100 percent certain whether or not governmental agencies will choose to allow Medicare billing on behalf of the patient to be legal, but our research points to “not.”

Here is what Hartley Medical asks of you: Please do not switch some or all of your pump practice from your current provider to one that submits billing to Medicare. If this is something that you have been contemplating, consider delaying your decision-making process. It appears that CMS will be announcing its decision regarding this matter in July or August, and enacting it by October. We recommend that you postpone your decision until CMS has  reached a definitive judgment on the legalities of this issue. Do not let these companies entice you to switch in their efforts to grow their own market share by capitalizing on questionable practices that could soon be banned.

I also must throw out these questions:

  • – Are these pharmacies operating at the highest of quality standards to ensure patient safety?
  • – By switching providers predominantly to alleviate the headaches of reimbursement billing, is patient safety being compromised?
  • – Are all aspects of these compounding pharmacies being researched and considered in these provider change decisions?

If you are not fully aware of the CMS billing issue, on December 15, 2011, the Centers for Medicare and Medicaid Services (CMS) issued news for Medicare Part B Providers to reflect Change Request (CR) 7397 – which clarifies policy with respect to restrictions on pharmacy billing for drugs provided “incident to” a physician service.

Pharmacies, Suppliers and Providers may not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration “incident to” a physician service, such as refilling an implanted drug pump. These claims must be denied. (See Medicare Claims Processing Manual, Publication 100-04, Chapter 17, section 50.B and Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, sections 50.3.)

Pharmacies may not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary. When these drugs are administered in the physician’s office to a beneficiary, the only way these drugs can be billed to Medicare is if the physician purchases the drugs from the pharmacy. In this case, the drugs are being administered “incident to” a physician’s service and pharmacies may not bill Medicare Part B under the “incident to” provision. (See Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, sections 50.3 and 60.1.)

Anticipating these changes, many practices across the country have taken steps toward developing efficient reimbursement policies and procedures. Due to the various, albeit subtle, differences seen across regional carriers, this development has been more difficult for some than for others.

Hartley Medical understands the challenges involved with reimbursement. As one of the nation’s leading compounding pharmacies, let us be a resource to you and your staff. We offer reimbursement guidance, and we can refer you to a reimbursement specialist within your specific region.

For more information, call 888.671.2888, or e-mail questions@hartleymedical.com.

Or visit Hartley Medical’s Knowledge Center by clicking here.

To read the CMS’s full Change Request, click here.

Watch the video above to listen as William Stuart, RPh, provides a commentary regarding Frequently Asked Questions (FAQs) for researching sterile compounding facilities. To receive a list of our FAQs, e-mail us at questions@hartleymedical.com or call 888.671.2888.