Medicare Drug Coverage Plans for Rheumatologic Medications

Although CMS has instructed the plan(s) to stop requiring prior authorization for methotrexate prescriptions, this has not been resolved. The ACR continues to work on eliminating this issue, but to minimize denials, it is very important for rheumatology practices to continue writing “Part D Drug” on every prescription for drugs that are sometimes covered by Part B. Keep in mind that the Part D plans are not permitted to pay for drugs that should be billed to Part B, and this statement is to inform them that the prescription is a valid Part D prescription.

If you are experiencing issues with any Part D plan as it relates to prior authorization requests for methotrexate prescriptions, contact the ACR practice advocacy department immediately via e-mail at [email protected].

Rheumatologists and patients report mixed experiences with the new prescription drug benefit

The ACR has compiled guidelines and tips on how to use the JW modifier and correctly bill Medicare for discarded drugs and biologicals. This modifier can be applied only to unused amounts from a single-dose vial or package.

In today’s busy rheumatology practices, the services of nurse practitioners, physician assistants, occupational therapists and clinical nurse specialists are a great asset for patient flow, as well as increased revenue. As the growth of nonphysician providers (NPPs) in rheumatology practices has evolved, it has become increasingly important to understand the incident-to rules and avoid the…

The Medicare statute states that items and services provided to beneficiaries must be “reasonable and necessary” to qualify for reimbursement. Although the Medicare program determines in specific cases whether an item or service is reasonable and necessary, it also issues policies, called coverage determinations, to instruct Medicare Administrative Contractors (MACs) what to reimburse providers for….

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