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Medicare Compliance & Reimbursement

Reader Questions:

ABN for Low-Paying Drugs?

Published on Sat Mar 12, 2011

Question: As you are probably aware, Pfizer is increasing the cost of Prevnar by $5.00. This is not a problem as most carriers are increasing their reimbursement to match. However, Healthnet, which is being officially consumed by United/Oxford on July 1, 2011, is not. Their answer is that they are going out of business, laying off people, and not adjusting their fee schedules whatsoever. Is this something I can pass along to my Healthnet patients for the next few months with a signed ABN or is that a violation of contract? Answer: Unfortunately, providing an advanced beneficiary notice (ABN) specific to this situation and charging the patient is not the answer. An ABN wouldn't apply because this isn't something the payer is denying. You are contracted with Healthnet so you shouldn't bill the patient because they aren't denying payment based a medical necessity issue. One option you have, however, is [...]
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