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An official publication of the ACR and the ARP serving rheumatologists and rheumatology professionals

Medicare D-lemmas

Ann Kepler  |  Issue: January 2007  |  

One of Dr. Morris’ patients encountered such a problem. The insurance plan refused to cover an infusion in the physician’s office and instead insisted that the patient go into the hospital in order to get the infusion covered. The patient had to find and pay for parking and then wait three hours for the procedure. The entire procedure cost three times as much in the hospital setting as it would have in Dr. Morris’ office. Dr. Morris and his patient complained to the insurance company, and the protocol changed.

Another common problem is obtaining prior authorization for drugs used in rheumatology that are also used in cancer treatment and transplantation, where they are covered by Medicare Part B. Having to obtain prior authorization is so common that a solution has been developed. Dan Fohrman, MD, of Bend Memorial Clinic in Bend, Ore., has worked as chair of a Regional Advisory Council for the ACR in conjunction with the CMS Physicians Regulatory Issues Team (PRIT) to propose a solution to this problem.

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According to Dr. Fohrman’s solution, physicians are now instructed to write “Rheumatology Part D” directly on the prescription form for these particular drugs. PRIT agreed to inform insurers about this idea, but so far not all of the insurers are aware of the solution.

In March 2006, PRIT issued another directive, but the problem of disseminating the wording on the prescription form now seems to lie with the pharmacies. Neither CMS nor the insurers have told all pharmacists—particularly independent pharmacists—about PRIT’s directive. “The layers of communication are numerous, and there is not enough incentive for insurers to spread the word,” says Dr. Fohrman. “So far, there is no consequence if they don’t comply.”

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Meet the Challenges of Medicare Part D

Here are some steps suggested by rheumatologists we interviewed to minimize the challenges of Part D:

Improve Practice Management Routines

  • Dedicate one person in your practice to be responsible for all insurance matters.
  • Take advantage of the State Health Insurance Assistance Programs, which have counselors in every state and some territories to provide one-on-one help with Medicare questions and problems.
  • Sign the Appointment of Representative form at the beginning of treatment of each patient to have it on file before a claim is denied.
  • Ask for contact information for each patient’s insurance provider for faster authorization requests.
  • Urge patients to contact congressional representatives with suggestions and complaints; keep a list of representatives’ addresses in your waiting room.

 

Increase External Communication

  • Volunteer to work with professional organizations, such as regional councils or Physicians Regulatory Issues Team.
  • Help establish a direct loop of communication from patients to doctors to government to insurers to pharmacists and back to patients.
  • Request that CMS make the Medicare Web site and written materials easier to understand.
  • Work with bureaucrats, politicians, and public health experts to develop, monitor, and assess coverage plans from a medical/treatment viewpoint.

 

Become an Advocate

  • Urge elimination of pre-approval for cheap first-line medications.
  • Suggest a change in the law to allow negotiation of drug prices with pharmaceutical companies.
  • Request that appropriate regulations be based on clinical decisions.

 

Support Ways to Reduce Patients’ Financial Burdens

  • Investigate and suggest patients use the Access to Benefits Coalition, Medicare Extra Help, and State Pharmaceutical Assistance Programs.
  • Suggest a sliding-scale pay system to government and insurers.
  • Suggest co-pay assistance, such as tax breaks, to pharmaceutical companies.
  • Investigate independent charities that receive donations from pharmaceutical companies to help beneficiaries with drug expenses.
  • Look for ways to eliminate the doughnut hole.

Confusion about Authorization Rules

Many rheumatologists believe the need to obtain prior authorization on so many rheumatic drugs grew from a lack of knowledge about rheumatic disease on the part of those designing the individual benefit plans. Gerald Eisenberg, MD, director of rheumatology at the Illinois Bone and Joint Institute in Des Plaines, describes the prior authorization problem as having a “hassle factor,” but he is more confused about why so many commonly used drugs require prior authorization. He thinks the reason may be a lack of interest in or an emphasis on cost-effectiveness.

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