Providers targeted for certain claims

Thursday, July 22, 2010

ALEXANDRIA, Va. - Medicare is demanding repayment for diabetes and other Part B supplies that it says should have been billed to other payers, but industry stakeholders say the products were dispensed in "good faith."

"We are worried this is just getting started and it's going to get bigger," said Susan Janeczko, director of long term, regulatory and policy affairs, for the National Community Pharmacists Association (NCPA). "They are going back to 2006, then they could work their way up."

The issue: Items that were dispensed to Medicare beneficiaries who, at some point during the prescription cycle, enrolled in either a Medicare Advantage (MA) plan, in which case the supplies should have been billed to the MA plan, or a home health agency (HHA) plan. Under an HHA, everything must be billed through the agency.

The provider had no way of knowing that the beneficiary switched plans. But Medicare wants its money back.

"So the pharmacy actually billed the service, it was approved, they got a check in the mail, and everything seemed fine," said Janeczko. "But when the auditors go back, they see there is an overlap of the service dates so they are telling the pharmacists that they are denying the entire claim for that DME product."

It's not just pharmacists that are getting squeezed. HME provider Mark Gielniak, vice president of Diabetes Plus in Warren, Mich., has repaid about $11,000.

"They sent a letter saying here's all the people that switched insurances and you should have billed the new insurance," he said. "If we give someone a three-month supply and halfway through they sign up for some other insurance--how could I know that?"

Many times, beneficiaries don't know what insurance they have, said Gielniak.

"They sign up for these programs and think they still have Medicare," he said. "They don't look at this as a replacement for their Medicare coverage, which it is."

In June, Reps. Tammy Baldwin, D-Wisc., and Bart Stupak, D-Mich., sent a letter to CMS Director of Program Integrity Kimberly Brandt in which they asked the agency to "immediately" instruct the Medicare Part B DME MACS to "cease their recoupment activities for services provided and billed in good faith by independent pharmacies."