Docs Must Join Medicare for Part D

A new regulation for Medicare Advantage and prescription drug benefit (Part D) programs hopes to save an estimated $1.615 billion in fraud over the next 10 years, and it does so with a number of changes.

The new regulations (CMS-4159-F) were influenced by 7,500 comments on a proposed rule displayed in the Federal Register Jan. 6. They include requiring some physicians to join Medicare. Final provisions include:

  • Requiring Part D prescribers to enroll in Medicare: CMS is requiring that physicians and eligible professionals who prescribe covered Part D drugs be enrolled in Medicare, or have a valid record of opting out of Medicare, in order for their prescriptions to be covered under Part D. Requiring prescribers to enroll in Medicare would help CMS ensure that Part D drugs are only prescribed by qualified individuals. The final rule allows more time – until June 1, 2015 – for implementation.
  • Revoking Medicare enrollment for abusive prescribing practices and patterns: CMS will have the authority to revoke a physician or eligible professional’s Medicare enrollment if CMS determines that he or she has a pattern or practice of prescribing that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements. CMS will also be able to revoke a physician or eligible professional’s Medicare enrollment if his or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked, or if the applicable licensing or administrative body for any state in which he or she practices suspends or revokes his or her ability to prescribe drugs.
  • Expanded prevention and health improvement incentives: The final rule expands rewards and incentive programs focusing on encouraging participation in activities that promote improved health, efficient use of healthcare resources,  and prevent injuries and illness.
  • Broadening the release of privacy-protected Part D data: CMS will expand the release of unencrypted, prescriber, plan, and pharmacy identifiers contained in prescription drug event records to give the public broader access to healthcare data pursuant to CMS’s policies and procedures for release of such data. CMS intends to preserve the privacy of Medicare beneficiaries.
  • Improving payment accuracy: The final regulation would implement the Affordable Care Act requirement that MA plans and Part D sponsors report and return identified Medicare overpayments. After the final risk adjustment deadline for a payment year, MA organizations will be allowed to submit data to correct overpayments but cannot submit diagnosis codes for additional payment. The provision codifies and clarifies rules regarding when Part D and MA plan sponsors must report and return overpayments.
  • Improving Medocare Advantage risk-adjustment data validation (RADV) audit appeals procedures: The rule strengthens RADV by combining error rate calculation appeals and medical record review-determination appeals into one combined process. The streamlined process will reduce administrative burden on both MA plans and CMS.
  • Expanding prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of healthcare resources and prevent injuries and illness.
  • Increasing  price transparency for network pharmacies: The final rule requires Part D plans and their pharmacy benefit managers to make available to contracted pharmacies the reimbursement rates for drugs under Maximum Allowable Cost pricing standards. In response to comments, this requirement will be effective beginning with contract year 2016.

“The policies finalized in this regulation will strengthen Medicare by providing better protections and improving health care quality for beneficiaries participating in Medicare health and drug plans,” said Marilyn Tavenner, CMS administrator. “The final rule will give CMS new and enhanced tools in combating fraud and abuse in the Medicare Part D program so that we can continue to protect beneficiaries and taxpayers.”

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Brad Ericson

Brad Ericson

Publisher at AAPC
Brad Ericson, MPC, CPC, COSC, has been publisher for more than nine years. Before AAPC he was at Optum for 13 years and at Aetna Health Plans before that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.
Brad Ericson

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Brad Ericson, MPC, CPC, COSC, has been publisher for more than nine years. Before AAPC he was at Optum for 13 years and at Aetna Health Plans before that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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