Big changes in Medicaid fraud scrutiny could mean big changes in drug pricing. Medicaid rebates and drug pricing issues are heating up, and drug manufacturers are examining their practices to set things right.
The latest example: Bristol, TN-based King Pharmaceuticals says it's adjusting its financial statements to reflect about $46.5 million in Medicaid overpayments between 1998 and 2002. That adjustment arose from an internal review by the audit committee of King's board of directors - a review that a Securities and Exchange Commission investigation sparked. The company says the adjustment relates to amounts it underpaid Medicaid under the Medicaid rebate program and other government drug pricing regimes. King has contacted the HHS Office of Inspector General, the Department of Justice and the Centers for Medicare & Medicaid Services on the matter, and expects to resolve it later this year. King isn't the first drugmaker to start looking into its compliance practices. Bristol-Myers recently launched an internal compliance review of its sales and marketing tactics. King says it is putting in place more aggressive compliance measures - including new information technology applications - to improve the accuracy of its rebate payments. CMS has posted the newest version of the home health PPS grouper software and documentation on its Web site at
www.cms.hhs.gov/providers/hhapps/. It's under the Prospective Payment System Coding and Billing section. Version 1.05 of the HH PPS case mix grouper software, which accommodates changes in OASIS reporting requirements, takes effect Oct. 1. In addition to the software, CMS also has posted grouper coding logic (pseudocode), test records and demonstration programs. Home care providers interested in expanding their businesses and boosting patient outcomes at the same time should check out new Medicare instructions on furnishing diabetes self-management training. CMS explains how to furnish - and bill for - covered diabetes outpatient self-management to eligible Medicare beneficiaries, according to a recent revision to the Medicare Home Health Agency Manual. But there is a catch: Home health agencies have to be willing to bill for the training services under Part B of Medicare. That means going by the same rules that durable medical equipment suppliers, physicians and other Part B providers follow, including collecting copays, CMS explains in Aug. 1 Transmittal No. 305. For coverage and billing details on diabetes outpatient self-management training, see the memo at
www.cms.gov/manuals/pm_trans/R305 HHA.pdf. If you let claims get denied in medical review, it's as good as throwing your money in the river. Tops on Palmetto GBA's latest claims denial list is failing to respond - either at all or on time - to an additional development request. The regional home health intermediary sends out ADRs to gather information from you, which medical reviewers use to [...]
