Health Information Compliance Alert

Published on Sat Sep 08, 2007 PDF

Overlooking this law will guarantee denials.

On Oct. 1, state Medicaid directors began enforcing a law that calls for all outpatient  Medicaid paper prescriptions to be written on a tamper-resistant pad.

If a beneficiary presents a prescription on noncompliant paper, there's a good chance Medicaid will not reimburse pharmacies. The program can and, in many cases, will deny claims for prescriptions written on paper from pads that don't meet, at a minimum, at least one state-specified tamper resistant criteria, according to the Centers for Medicare & Medicaid Services.

CMS allows that pharmacists can provide an "emergency fill" of a non-compliant written prescription. But in order to be paid in that circumstance, the pharmacist would have to contact the prescriber and receive a verbal, faxed, electronic or compliant written prescription within 72 hours.

The new federal tamper-resistant pad law affects only paper prescriptions. The new mandate does not affect electronic prescriptions, faxed prescriptions, or prescriptions conveyed by telephone. Prescriptions covered by a managed care plan are also exempt from the law.

It remains to be seen how state Medicaid departments will respond to CMS' guidance regarding the law. Problems are likely since CMS gave states only about six weeks to notify providers, pharmacies, and recipients, insiders agree.

In other news...

• Doctors' claims data could be on the Internet soon. A consumer group, Consumers' Checkbook, won a lawsuit, so Medicare must release data on your physicians' services. The data covers Illinois, Maryland, Virginia, Washington and Washington, DC. The group plans to list each doctor in those states, along with how may times each doctor has performed each procedure. That way, patients can choose to go to a doctor who performs a particular procedure more often, according to the American Medical Association's news site.

• The Recovery Audit Contractors, which receive a bonus every time they recoup your Medicare payments, will soon be spreading nationwide. So far, there have been a few isolated problems with the RACs, says William Rogers at the Centers for Medicare & Medicaid Services.

The RACs have requested "unreasonable amounts of paperwork for unreasonable amounts of claims," or else requested paperwork for claims where the time limit has already expired, Rogers notes. But CMS has been working hard to create policies to minimize the impact of the RACs on doctors. Every RAC will have a medical director, for example.

CMS is also working on rules, which will make the RAC program "a lot less burdensome," Rogers says.