To review the March 10, 2014 Guidance, I have divided it into the categories of the good things and the bad things about it. It always helps to start with the positive, so... in no particular order:
The independent reviewer component described in the December 6th Guidance is on hold for future rulemaking. This is good news because at least CMS did not try to figure out something so critical without taking the time to give it more thought and hopefully input from stakeholders.
- During this interim period when there is no process for dispute resolution, the Part D plan sponsor is expected to accept the hospice's determination / documentation that a drug is unrelated to the terminal illness or related condition and process the claim under Part D. This appropriately respects the determination on relatedness made by the hospice physician and also helps ensure that patients receive needed medication in a timely manner.
- CMS did not use the troublesome "virtually all" 1983 preamble language. Nevertheless, the memo indicates virtually the same thing with probably the most significant statement in the entire Guidance: "We expect drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances. Therefore, the sponsor should place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who have elected hospice to determine whether the drugs are coverable under Part D." [bold text in original document]
- With the requirement to obtain prior authorization on all drugs for beneficiaries, CMS is at least implicitly acknowledging that there may be drugs (even analgesics) that could be unrelated to the terminal illness and is now allowing for case-by-case determinations. This is very good and a significant shift from its stance several months ago to deny entire classes of drugs and say case by case determinations are not necessary.
- Hospices may proactively initiate the PA process and submit documentation on unrelatedness prior to submission of claims under Part D and plan sponsors should accept the documentation and consider the PA requirements are fulfilled. Again, this will help streamline an already cumbersome process and is in the interest of ensuring patients receive needed medications as soon as possible.
- The effective date is delayed until May 1, 2014 as opposed to March 1, 2014. This is not as good as what NHPCO had asked for (October 1, 2014) but at least there is some breathing room. However, where this borders on the bad/ugly is that in the meantime, Part D plan sponsors can do whatever they want with regard to reviews, authorizations or recoupments. Confusion will continue to reign.
- If a hospice provides a patient with a drug the patient wants but the hospice does not consider reasonable or necessary, the hospice will be required to issue an Advance Beneficiary Notice (ABN) to the patient to inform him or her of payment liability. This will help alleviate some confusion about payment responsibility.
Have I missed anything? Let me know in the comment section below.
Now on to the bad...
Posted by Heather P Wilson, PhD, CEO, Weatherbee Resources, Inc