Medicare Compliance & Reimbursement

Keep education in mind to counter off-label denials

All too often, patients' myths and misconceptions about Part D leave them dangling with no coverage for a drug their doctor has prescribed--and leave you with an ethical dilemma. Help them back to solid ground with some quick coaching on their rights regarding exceptions and appeals.

1. Clients should contact their prescription drug plans (PDP) to seek an exception in two instances:

• If a needed medication is not on the PDP's formulary, find out if the drug has been dropped from the formulary for reasons other than safety. If so, a beneficiary can request that the PDP cover the drug.

• Also, a beneficiary can ask for an exception if the prescribing physician believes that the drugs on the formulary cannot meet a patient's needs.

2. Clients aren't the only ones who can request an exception. The person's legally authorized representative can also start the process, as can the prescribing physician.

3. Requests for exceptions need physician back up. Essential to the request: an oral or written supporting statement from a doctor demonstrating the drug is necessary. Generally, PDPs must grant these exception requests when making a determination that it is medically appropriate.

4. Beneficiaries can push for quick turnaround--in some cases. By law, PDPs must respond to requests within 72 hours. But if a patient needs a drug more quickly, an "expedited request" is in order. These special requests can be made if going without the drug jeopardizes "life, health or ability to regain maximum function." PDPs have just 24 hours to respond to an expedited request. If a PDP grants a request, the exception applies to refills during the same calendar year as long as the physician continues to prescribe that drug and the drug continues to be safe, according to the Disability Policy Collaboration.

5. If a PDP denies an exception request, a beneficiary can appeal the decision. The appeals process includes a second review by the plan, a review by an independent review entity, an administrative law judge review and, finally, consideration by the Medicare Appeals Council.