Medicare Compliance & Reimbursement

Plus: Decision rules out shortcuts in drug claim appeals process

The chances of averting a 15-percent Medicare cut (spread across 2008 and 2009) just got a lot slimmer.

The House of Representatives agreed to drop Medicare provisions from its children's health bill in order to agree on a consensus bill with the Senate, according to Capitol Hill insiders.

Physicians have to hope Congress can get its act together before the end of the year to pass a separate Medicare bill that prevents the 10-percent cut scheduled for 2008. The legislative calendar is fast running out. And if Congress doesn't address this year the additional 5-percent cut scheduled for 2009, providers can't count on Congress passing a fix in 2008, an election year.

The American College of Physicians sent letters to Congressional leaders expressing "deep concern and disappointment" that Congress had dropped Medicare fixes from the children's health bill.

ACP president David Dale urged Senate leaders to work with the House to "reach prompt agreement on Medicare legislation to preserve and improve access to care for America's seniors."

The American Medical Association issued a statement saying it was "deeply disappointed that congressional leaders have decided to defer action to stop Medicare cuts to physicians."

"Doctors want to continue caring for Medicare patients, but many are between a rock and a hard place," the AMA statement added.

In Other News...

• Beneficiaries can expect to continue to jump through Part D's administrative appeals hoops when prescription drug plans deny coverage of needed drugs.

Spotlight: A cancer patient who claims that her Medicare Advantage plan improperly classified her chemotherapy drugs must first exhaust her administrative remedies under Medicare before she can seek judicial review of her claims. That decision comes from a federal district court in Florida (Masey v. Humana Inc.).

In cases in which a party's claims are "inextricably intertwined" with a claim for Medicare benefits, judicial review is not available until the party has presented his claims to the U.S. Department of Health & Human Services and run through all options in the administrative appeal process, wrote Judge Elizabeth Jenkins, writing for the District Court for the Middle District of Florida on Aug. 16.

Darly Masey alleged in the case that Humana breached its Medicare Advantage contract when it classified her chemotherapy drugs as covered by Part D rather than Part B. Part B would have covered 100 percent of the associated costs, but Masey incurred "thousands of dollars" in drug expenses under Part D.