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Medicare Compliance & Reimbursement

HEALTH PLANS:

Streamline Part D Turnaround Time To Head Off Potential Regulatory Changes

Published on Mon Mar 20, 2006

Most EHR systems fall to track revisions' sources, study shows.

Lagging Medicare Part D drug reimbursements have pharmacists seeing red--and they're pointing the finger at private insurers. Payers will need to speed up their reimbursements, or the Centers for Medicare & Medicaid Services might do it instead.

Pharmacists are complaining that the Medicare drug benefit is costing them money and threatening to put many drugstores out of business, according to a recent New York Times report.

"Pharmacists are being asked to bankroll the [Medicare drug] program. Many have to dig into personal savings and take out loans to stay in business," pharmacist Richard E. Beck tells reporters.

Private Medicare drug plans should keep one ear to the ground--a battalion of pharmacists from Texas recently took the battle straight to the White House and met with Karl Rove, senior advisor to President Bush. Bill C. Pittman, the Texas State Board of Pharmacy's former president and current Pharmacists for Bush chairman, spearheaded the group.

"If pharmacists don't receive immediate relief, some will go broke. Others are hurting so bad that they will choose not to participate in Medicare and Medicaid," says Pittman in a statement.

Carriers that are taking longer to process Part D payments should expect pharmacies to file a complaint.

In a good-faith effort, pharmacists took the initiative to foot the bill for beneficiaries' Part D drug claims during the plan's rocky rollout.
But many feel that private plans forced them into "take it or leave it" drug contracts and are now forcing them to wait too long for reimbursements that turn out to be too little.

The seven- to 15-day turnaround on Medicaid and commercial insurance claims that pharmacists previously enjoyed is now taking 30 days or more for Medicare reimbursement. Plus, private Medicare insurers are typically reimbursing pharmacies less than they received through Medicaid for the same services. CMS has promised to investigate pharmacists' complaints, so carriers had better watch out; if pharmacists are able to make big enough waves, CMS could require them to decrease their turnaround time and adhere to stricter reimbursement regulations.

Competing Pharmacies Could Attack Carriers' Co-Branding Arrangements

Although the pharmacists met with Rove on behalf of pharmacists across the country, that didn't prevent them from engaging in some partisan politicking.

"Most independent community pharmacists are small-business Republicans," the group points out in a report they presented to Rove and Allan B. Hubbard, President Bush's assistant on economic policy. "Pharmacists want to be supportive of this administration, and they can play an active role in the midterm elections. But pharmacists need to be able to point to some corrective actions being taken by the administration."

If pharmacists push hard enough, carriers may end up paying the price. Pharmacists' political connections may give them enough clout to influence the federal regulation of private drug plans that offer Part D coverage. Taking proactive steps now to streamline the Part D reimbursement process could save carriers trouble catching up later on if CMS imposes harsh reimbursement standards.

At the very least, carriers should start looking for ways to cut their Part D reimbursement turnaround time in half--before CMS does it for them. Pharmacists told White House officials that they would like to receive electronic reimbursements within seven to 10 days. In addition, carriers might consider implementing financial incentives that would help pharmacists reduce costs by encouraging them to dispense generic drugs in place of their brand-name alternatives.

And that's not all. Pharmacists' ability to sway the government could also put carriers' co-branding agreements at risk. When they met with White House officials, pharmacists also asserted that Medicare shouldn't allow drug plans to promote specific drugstores on member ID cards. Such promotions mislead benes into thinking that they can fill their prescriptions only at that particular pharmacy, the group argues.

"You don't have advertising on a Social Security card. Why would you have advertising on Medicare prescription drug cards?" remarks Marvin D. Shepherd, a professor at the College of Pharmacy at the University of Texas.

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