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AIS's Health Business Daily
Featured Story July 29, 2008 Vaccine Shift From Part B to Part D Results in a Variety of Approaches Reprinted from SPECIALTY PHARMACY NEWS, a monthly newsletter designed to help health plans, PBMs, providers and employers manage costs more aggressively and deliver biotechs and injectables more effectively. By Angela Maas, Managing Editor, amaas@aispub.com The “buy-and-bill” method by which physicians purchase drugs themselves and are reimbursed for them took another blow earlier this year. On Jan. 1, CMS shifted coverage and administration of the majority of vaccines from Medicare Part B to Part D. The move, contend industry experts, caught many physicians off guard and sent Part D plan sponsors scrambling for a way to have these vaccine claims adjudicated. And the burden has shifted in some instances to beneficiaries, who are paying out-of-pocket for vaccines and submitting claims themselves to their Part D plans. All Part D formularies for contract year 2008 and later must contain all commercially available vaccines, unless they are available for reimbursement under Medicare Part B. Now, only a few vaccines fall under Medicare Part B, while the majority are covered under Part D. Prior to the shift, physicians had these vaccines in their offices and would bill for them under Part B. But since physicians do not bill under Part D, the recent move caused some problems. Judi A. Grupp, president and CEO of ActiveCare Network LLC, a company that aims to improve access to affordable chronic biological services, tells SPN that most physician practice management systems do not accommodate Part D billing, and most physicians are not able to administer these vaccines in their offices. Physicians can no longer bill for vaccines unless they have specialized systems. And doctors are willing to take an additional adjudication system only if they know they will get use out of it, she contends. “Without access to a pharmacy billing system, physicians cannot validate benefit coverage, determine patient out-of-pocket responsibilities or electronically submit claims for reimbursement,” thus forcing beneficiaries to pay for their vaccinations in advance and then submit a claim for reimbursement, she says. Moving the vaccine coverage to Part D “didn’t fit very well with the way the industry adjudicates claims,” agrees Britt Pim, senior director of Medicare product management for Express Scripts, Inc. This shift prompted PBMs and drugstores, working through industry associations, to come together and discuss how they were going to address the situation, he says. Change Was Surprise to Many Physicians Compounding the problem was the fact that few physicians knew of the impending shift. This change “probably could have been communicated to [physicians] more effectively,” says Pim. Feedback from some of Express Scripts’ health plans and from some of the PBM’s employees themselves was that as of late last year and early this year, the shift “was a surprise” to many physicians. When it made the change, CMS offered sponsors multiple options to provide adequate vaccine access to beneficiaries. Grupp recommends a “turnkey solution” that would simplify the vaccination process for physicians. Under this solution, physicians unable to provide vaccines in their offices could fax prescriptions to a “national vaccination network” consisting of clinics that will administer the vaccine, validate beneficiary coverage, determine a beneficiary’s out-of-pocket responsibilities and electronically submit claims to Part D plans for reimbursements. ActiveCare Network teams with NuFactor Specialty Pharmacy to provide its turnkey product, VaxAmerica, to Part D plans. These Part D plans do not have to contract with the individual clinics in the network, just with VaxAmerica. Other organizations
also are offering vaccine-related systems. For example, Dispensing Solutions,
Inc. (DSI) has developed a Web-based product that processes in-office
Part D vaccines electronically. It provides patient-specific vaccine
coverage information and allows for online claims processing. However,
it allows only Part D plans already participating in DSI’s eDispensing
network to participate. Express Scripts, says Pim, has contracted with
pharmacies to make these vaccinations available to beneficiaries. It
is then the pharmacies’ responsibility to make sure that there
is someone available to provide the vaccine. Some plans are informing
beneficiaries where they can get vaccines and helping physicians adjudicate
claims. |
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