Infusion Drug Payment Amounts to Change with April Update
The 21st Century Cures Act, signed into law Dec. 13, 2016, changed the way certain Medicare Part B drugs infused through durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items will be paid beginning in April.
Curing Improper Payments
Section 5004 sets payment amounts for Part B drugs infused through DMEPOS items using the Average Sales Price (ASP) plus 6 percent—the same methodology used for most physician-administered drugs. Previously, payment amounts were based on manufacturer sticker prices that were in effect in 2003. The Office of Inspector General found this methodology was overpaying some drugs while underpaying others.
Medicare will use the April 2017 ASP drug pricing files and, if released, the revised January 2017, October 2016, July 2016, and April 2016 ASP drug pricing files to determine the payment limit for claims of separately payable Medicare Part B drugs processed or reprocessed on or after April 3, 2017.
Quarterly payment files will be applied as follows:
|Files||Effective Dates of Service|
|April 2017 ASP and ASP NOC||April 1, 2017, through June 30, 2017|
|January 2017 ASP and ASP NOC||Jan. 1, 2017, through March 31, 2017|
|October 2016 ASP and ASP NOC||Oct. 1, 2016, through Dec. 31, 2016|
|July 2016 ASP and ASP NOC||July 1, 2016, through Sept.30, 2016|
|April 2016 ASP and ASP NOC||April 1, 2016, through June 30, 2016|
Payment for DME infusion drugs that do not appear on the ASP Drug Pricing Files will be determined by the Medicare administrative contractors in accordance with the Medicare Claims Processing Manual, Chapter 17, Section 20.1.3.
Payment allowance limits under the Outpatient Prospective Payment System are incorporated into the Outpatient Code Editor through separate instructions in Chapter 4, Section 50 of the Medicare Claims Processing Manual.
Source: MLN Matters Article MM9945, release date Dec. 13, 2017