Medicare Compliance & Reimbursement

Plus:  Stakeholders call for revisions to new price list.

Say goodbye to Mark McClellan as administrator of the Centers for Medicare & Medicaid Services (CMS). McClellan, a physician, lasted just two years in the job but oversaw the introduction of the Part D drug benefit and other sweeping changes in Medicare, the Boston Globe notes. Mark McClellan announced his resignation as CMS administrator on Sept. 5, saying he will likely step down by early October.

A replacement for McClellan has not been named, but potential nominees include CMS Deputy Administrator Leslie Norwalk and Herb Kuhn, director of CMS' Center for Medicare Management. McClellan's successor could face tough confirmation hearings if the Democrats gain control over one or both houses of Congress, the Globe predicts. Democrats will have searching questions about the dizzying complexity of the Part D program and other recent changes, experts predict.

New Price List Problematic, Suppliers Say

The feds' effort to "ensure accurate Medicare reimbursement" for power mobility devices (PMDs) is off to a misguided start, says industry representatives.

In June, CMS released long awaited new Healthcare Common Procedural Coding System HCPCS) codes for PMDs. Aiming for an Oct. 1 implementation of the new codes, CMS then released draft information regarding pricing for the various new codes on Aug. 10. The agency's brief comment period ended Aug. 25.

CMS has proposed supplementing manufacturer-suggested retail prices with the retail prices culled randomly from the Internet.

"The use of Internet merchants' pricing data in developing fee schedules for the new codes will result in inaccurate Medicare payment for these products and create what may be insurmountable barriers to access for beneficiaries," charges the American Association for Homecare in an Aug. 25 letter to CMS.

Medicare-enrolled suppliers can't afford to compete with the discounted prices of Internet retailers, charges Eric Sokol of the Power Mobility Coalition in Washington, DC, citing fundamentally incompatible business models. That equals potential problems in access for beneficiaries, he warns.

PMD manufacturers and their representatives also report that a list released by the Statistical Analysis Durable Medical Equipment Regional Carrier just prior to CMS' pricing guidance misclassifies many or even most of their products. Manufacturers including Invacare of Elyria, OH, and Exeter, PA-based Pride Mobility Products have called CMS' attention to the pricing discrepancies.

Fee schedules for the new HCPCS codes are expected to be published as part of the October durable medical equipment, prosthetics, orthotics and supplies update. After the publication of the fee schedule, the DME Program Safeguard Contractors will develop an article that will provide additional information on this subject, reports Palmetto GBA.

Part D Benes Have Better Access To Cancer Drugs

Researchers discovered that nearly all the 3,000 Medicare Part D plans they studied covered most cancer drugs, including brand-name ones. Also, the cancer drugs that plans covered the most had low copayments.

Few plans--less than 5 percent--had quantity limits on cancer-drug supplies per patient, and no plans required step therapy (where a patient must fail on one drug before they can receive another), according to a study spearheaded by Jennifer Bowman, a director at Avalere Health, LLC, and her colleagues. Researchers did find that some plans required prior authorization for some drugs, but mostly for brand-name cancer drugs.

"This means that patients can have a very different experience in terms of their access to drugs, depending on the type of cancer they have and the specific type of drugs they need," Bowman said in a Sept. 12 statement.

The study appears in the latest issue of Health Affairs, available at http://content.healthaffairs.org/current.shtml.

In Other News...

 · The American Medical Association (AMA) wasn't idle during the August Congressional recess. The AMA and the Indiana State Medical Association met with local media and physicians in Indianapolis as part of its National House Call campaign. The AMA is encouraging patients to contact their members of Congress to urge them to stop the roughly 40-percent cut in Medicare payments to physicians over the next nine years.