Part B Insider (Multispecialty) Coding Alert

Published on Thu Jul 12, 2012 PDF

Give patients this info when they balk at filling new prescriptions due to 'donut hole' cost concerns.

Although the Affordable Care Act (ACA) was signed into law over two years ago, it's still a hot topic and is back in the news this week after the Supreme Court's latest ruling that the law is Constitutional. But Part B practices still have questions about what the ACA means for their day-to-day operation. Today we've got the top three facts that will help you see the law's impact on your daily practice.

Fact 1: The ACA Does Not Impact Instability in the Conversion Factor. As you read on the front page of this issue of the Insider, Medicare payments are set to drop by 27 percent in 2013, unless Congress steps in to change that. What confuses many physicians is whether the ACA changes that fact. Unfortunately, the two are not tied together--the ACA has no impact on the proposed Medicare Physician Fee Schedule.

"The Sustainable Growth Rate (SGR) formula is not addressed in the ACA and is not affected by the ruling," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. "Congress is expected to act to keep rates frozen for the foreseeable future. This is a political hot potato that Congress just does not want to touch."

Bottom line: Although the ACA provides scores of benefits for patients, you'll have to wait and see what happens in Congress to determine what the 2013 conversion factor will end up being for 2013 and beyond.

Fact 2: You Can Now Collect for Many Preventive Services. Ever since the ACA was voted into law, you've been able to collect from Medicare for annual wellness visits (AWVs), tobacco cessation counseling, cholesterol screenings, HIV testsing, cancer screens, and certain vaccinations, among other services.

According to CMS statistics, 1.35 million Medicare patients have taken advantage of the free AWV, and more than 16 million Medicare beneficiaries have gotten at least one free preventive service so far in 2012 because of the ACA regulations.

"Millions of Americans are getting cancer screenings, mammograms and other preventive services for free thanks to the health care law," said HHS Secretary Kathleen Sebelius in a July 10 statement. "These new benefits, made possible through the health care law, are helping people stay healthy by giving them the tools they need to prevent health problems before they happen."

For details on how to bill and code for these preventive services, check out back issues of the Insider on Codify. In addition, CMS offers tips on reporting preventive medicine services that are billable under the ACA at www.healthcare.gov/law/features/65-older/medicare-preventive-services/index.html.

Fact 3: The So-Called 'Donut Hole' Is Still in Place. Although your practice isn't involved in billing for a patient's prescriptions, many Part B practices field questions from patients about this topic, particularly when your physician plans to prescribe a new medication. Patients often tell doctors that they don't want to fill new prescriptions because they fear high out-of-pocket costs due to their status in the "donut hole." However, you can tell patients that they have options.

Background: Under the ACA, beneficiaries have to cover their drug expenses once prescription costs hit $2,930. After patients spend $4,700 out of pocket, coverage kicks in again. Therefore, the costs between those two figures, which patients have to pay for on their own, are known as the "donut hole."

What you can advise: If patients balk at filling much-needed prescriptions due to donut hole issues, let them know that CMS has provided resources. Patients who had to pay for medications within this coverage gap most likely already received a $250 government rebate to help pay for the medications.

In addition, patients can get a half-price discount on covered brand-name medications while they are in the donut hole, CMS says. The donut hole will be eliminated by 2020.

To direct patients to resources on how to get these government benefits to help with their medications, have them visit www.healthcare.gov/law/features/65-older/drug-discounts/index.html. For patients without internet access, you might consider printing out a few copies of this information so patients know how they can get assistance with their drug costs.