Between 2011 to 2016, Medicare fee-for-service drug spending increased from $17.6 billion to $28 billion under Medicare Part B. Medicare Part D total spending has almost doubled from 2010 to 2016, increasing from $77.5 billion to $146.1 billion, with costs projected to increase further, according to the Centers for Medicare & Medicaid Services (CMS). Drug prices for beneficiaries in the U.S. are also on the rise and can be found in places like Europe for up to 80% cheaper, according to NPR. The cause? A market full of hurdles and barriers to creating biosimilars (drugs with the same or similar active ingredients as the original and often available at a reduced price); current laws that prevent vendors from negotiating drug prices; and outrageous prices for essential drugs that treat ever-more-common chronic conditions, such as cancer, rheumatoid arthritis, and hepatitis C.
Earlier this month CMS announced the release of a new app, “What’s Covered,” that allows people to quickly look up what Original Medicare covers using their mobile device. In addition to the “What’s Covered” app, CMS is enabling beneficiaries to connect their claims data to applications and tools developed by innovative private-sector companies to help them understand, use, and share their health data through Blue Button 2.0.
Surgical dressings are limited to primary dressings, which are therapeutic or protective coverings applied directly to wounds or lesions that are on the skin or are caused by an opening to the skin, and to secondary dressings that are therapeutic or protective (i.e., are needed to secure the primary dressing).
If a provider discovers a claim was paid incorrectly or in error, it is important that he or she takes the initiative to make a correction. Adjustment claims are also appropriate to add other charges to the claim, such as if an invoice for an ancillary item is received after the billing has been completed or was simply overlooked when the claim was prepared. Keeping Medicare funds that were improperly paid is considered Medicare fraud.
In response to a 2017 OIG report noting that some pharmacies billed Medicare incorrectly for Part B claims using the KX modifier for immunosuppressive drugs, CMS has published several resources to clarify manual instructions and help pharmacies document the medical necessity of organ transplant and eligibility for Medicare coverage. Resources include the following:
Medicare covers urinary catheters and external urinary collection devices when they are used to drain or collect urine for a resident with permanent urinary incontinence or permanent urinary retention. According to CMS, permanent urinary retention occurs when the condition is not expected to be medically or surgically corrected within three months. The urology benefit under Medicare Part B does not cover the treatment of chronic urinary tract infection or other bladder conditions if the permanence requirement is not met.
Medicare’s new method of calculating payment rates for laboratory tests, intended to reduce Medicare spending by $360 million in the first year, could cost the agency billions in overpayments, according to a recent report from the U.S. Government Accountability Office.
CMS established new payment rates for Medicare Part B laboratory services, effective in 2018. CMS was required under the Protecting Access to Medicare Act of 2014 (PAMA) to base the new rates on private payer data rather than on historical laboratory fees, which were typically higher than the rates paid by private payers. CMS is gradually phasing in reductions to Medicare payment rates, limited annually at 10% from 2018 to 2020, as outlined in PAMA.