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    Medicare Part B drug billing revisited

    How proposed demonstration project and a possible change in ‘brown bag’ rules may affect your practice

     

    Watch your processes

    Last but not least, if you are going to administer the drug, you have to take precautionary steps to be sure that you get paid for the drug.

    Read: What urologists need to know about APMs

    When we are reviewing the payment history of a practice, there is nothing more painful for us to see than a high-priced drug, or a series of the high-priced drugs, that have not been paid and will not be paid because of a process error, noncompliance with payer rules, or timely filing. Don’t ever let that happen to you again!

    Drugs, because of their cost and their marginal reimbursement, deserve extra precautionary steps to ensure compliance with all payer rules. We detailed in our article, “How to get paid for drugs administered in the office” (March 2014, page 32), the steps that should be taken to ensure compliance and payment. We will summarize the key points again.

    Each drug dose should be tracked, independently, from scheduling until the money is in the bank. We suggest that you use a separate system to track all drugs. Many of you have used “LuproLink” for leuprolide (Lupron), or “AIMS” for triptorelin (Trelstar). AIMS has been upgraded and can be used to track all drugs.

    The key functions that should be followed for each dose of each drug are summarized below (for more detail, please refer back to the original article):

    • insurance verification
    • preauthorization, etc.
    • collect co-pay from patients
    • track each payment as a separate line item
    • specifically check status on each claim.

    Conclusion

    The changes relative to drug reimbursement in Medicare add to a long list of issues that each practice struggles with in providing care to a growing patient population. Balancing appropriate patient care with the responsibility to your business is becoming more and more difficult. In the end, you will have to determine whether your practice can adapt to the business practices required to allow you to meet the needs of your patients, or if you will need to find a partner to help address patient care or change your model of participation with your payers altogether. We have helped many meet these changes and have watched many others initiate successful changes; unfortunately, we have seen far too many ignore the need for change and pay a significant price. There is no one-size-fits-all solution, but we are pleased to see that there are some very determined and creative urologists continuing to meet the needs of their patients while balancing the health of their business.

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    The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.


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    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.

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