Medicare Compliance & Reimbursement

Plans get creative to secure best deals while complying with antitrust laws. A draft revised policy from the Centers forMedicare & Medicaid Services issued July 8 could pave the way for smarter coverage of your end stage renal disease patients. But first CMS wants to hear your take. For potentially anemic patients, the draft policy would monitor:

both hemocrit and hemoglobin levels;
the incentives that exist to keep these levels in the 'target range'; and
excessive dosing of erythropoietin. CMS currently restricts reimbursement for EPO claims to a post-payment review of beneficiaries who claim a rolling average hematocrit level of 37.5 percent or greater. Under that policy, however, many who need the drug may end up ineligible for coverage. According to the CMS Public Affairs Office, the National Kidney Foundation recommends a hematocrit level within the range of 33-36. But comments submitted to CMS said that natural variability in individual patient hematocrit levels makes that a difficult target to maintain. The proposed policy will consider both hematocrit/hemoglobin and EPO dosage levels, and should "monitor incentives to keep hemoglobin/hematocrit levels in the target range while discouraging excessive dosing of EPO," the release said.

"We invite the ESRD community, national experts and patients to provide comments on this specific proposal and its potential effects on patient outcomes," said CMS Administrator Mark McClellan. CMS will not issue a final EPO monitoring policy until it receives input from the ESRD expert community. To view the proposal, go to: http://www.cms.hhs.gov/coverage/8b.asp. Lesson Learned: Proposed changes could improve Medicare's coverage of EPO claims.