Here’s something to watch for, especially with the movement toward bundling. This also might impact home dialyzers instead of in-center.
I just got a new supply of Aranesp this past week. For all practical purposes, this was my first supply from my Wellbound clinic. The last couple, they somehow got them from the hospital the docs are associated with. Rather than shipping out of their own inventory, they sent an Rx to a pharmacy. Thye bill came back with $50 co-pay and the remainder to my secondary insurance, Blue Cross/Blue Shield. I was pretty ticked and told both the clinic and the pharmacy I wouldn’t pay the $50.
Here’s the deal; when your ESA is part of your dialysis, then Medicare Part B gets charged; if an Rx is made out, then either you or your secondary insurance if they handle you meds, or Medicare Part D.
Obviously this is a way for HHD clinics to get around the whole Medicare process, and in factl, would probably recoup more money. I’ve insisted that Rx’s are not written in the future – let’s see what happens.
Your dialysis provider is supposed to be providing dialysis equipment and supplies under the composite rate and is supposed to provide certain drugs (like ESAs) that you need for dialysis and for now can bill Medicare separately for them. Your dialysis provider should be purchasing Aranesp or Epogen for you and making sure you get it. In my experience, patients received their EPO to take home during clinic visits. Your provider SHOULD NOT be sending a prescription for EPO to your Part D plan. ESAs (Aranesp, Epogen) are Part B covered drugs for dialysis patients and patients with CKD (Aranesp or Procrit) who meet criteria to get them. According to a provision in the Medicare Modernization Act, Part D is NEVER suposed to pay for a drug that should be Part B covered.
Here are two documents that CMS (Centers for Medicare & Medicaid Services) has posted to try to explain when Part B should pay and when Part D should pay for certain drugs that could be covered under either plan. As you’ll see, it says that EPO is a Part B drug for dialysis patients. It doesn’t matter whether the patient is receiving treatment in a dialysis clinic or at home. I’d share these documents with your dialysis provider.
There is an advantage to having EPO billed under Part B.
If Part B is billed and you have a secondary insurance (like a Medicare supplement/Medigap plan or Medicaid), it will pick up the 20% of Medicare Part B covered drugs. You will pay nothing out of pocket.
If Part D is billed, anyone who doesn’t get extra help will have to pay a copay and if you don’t have gap coverage, once you hit the gap (which you likely would), you’d have to pay 100% until your drugs cost enough to reach the Part D catastrophic benefit after which you’d pay 5%.
Did not receive EPO at my monthly neph apointment last week. Was told that they have to have it mailed to me for now on. I asked why this is and no one knew ??? Is this due to Medicare’s new policy? I did not receive my EPO in the mail last week and called to find out what happened Fri… They said the order will go out on Mon.and be shipped overnite delivery. Since I got no EPO last week, I am wondering if I will need a double dose this week.
Medicare does not have a policy related to a clinic mailing vs. dispensing EPO at the dialysis clinic.
Never take more EPO than what your doctor prescribed without talking with your doctor or nurse. Did your clinic draw your blood for H/H when you were there last? Does your nurse have the results yet? If you take more than you need for your current level of hemoglobin, your hemoglobin could go up too high too fast, which could cause health and access problems and/or could force your clinic to reduce your dose 25% or stop your EPO entirely until your hemoglobin drops down to the target range of 11-12. Starting and stopping EPO typically makes people feel like they’re on a roller coaster as far as their fatigue/energy is concerned. People typically feel much better when their hemoglobin level is as stable as it can be over time.
Beth,
I meant I did not get any EPO last week, because they failed to give it to me due to their new policy. Rather than giving it to me at my monthly visit to take home with me ( I give it at home ), they told me it would be mailed to me for now on. So I totally missed getting EPO last week. I thought this new policy might be Medicare related. What other reason would there be for EPO being mailed?
Also, can you spell out in simple terms what the new Medicare law means re EPO? I have seen what appears to me to be mismanagement of EPO. Iron is not given when needed so it takes more EPO to keep the hgb up. Did units make more $$$ on EPO by doing this? With the new law is it not possible to profit anymore off of EPO?
Are you a Method I or Method II patient? This could make a difference although nothing has changed with that policy either.
– If you’re a Method II patient, your Method II supply company is supposed to provide the EPO and any other IV or injectible medications you give yourself at home.
– If you’re a Method I patient, the dialysis facility is supposed to provide these drugs and bill Medicare for them separately from the dialysis treatments.
Ask who they’re billing for your EPO. Do they have information on your Part D plan? If not, they must be billing your Medicare and/or other insurance.
There has been controversy about what a safe hemoglobin/hematocrit is for people with CKD and those with cancer. Unfortunately that controversy has spilled over onto dialysis patients even though the reseach that raised the concern did not include patients on dialysis. Facilities have had to record H/H on their bills to Medicare to prove that it’s needed. If a patient’s H/H is too high and they don’t reduce the dose 25%, they could get reduced payment from Medicare.
I don’t know how commercial insurances pay for EPO or whether they follow Medicare’s guidelines. If you have insurance other than Medicare that pays for EPO, it’s possible it has to be ordered from a specific pharmacy and that’s why it’s shipped.
However, the only way to know for sure is to ask the home training nurse or the facility manager/billing personnel why this change has occurred. It could just be that they didn’t get their EPO shipment in time to give it to you while you were there.
Over the years, Medicare has changed the rules many times regarding when to start, stop, hold, cut doses, how to bill, how much is reimbursed, etc. for EPO. EPO is an expensive drug. Medicare reimburses for EPO at pretty much what providers pay for it assuming the bottle held the amount it says it holds. Medicare pays for the syringe to administer it. Medicare doesn’t pay for the time to administer it. There is a profit in it for LDOs (large dialysis organizations) because they can bulk buy EPO and get better prices from Amgen based on quantity. Small providers pay more for it because they don’t have the bargaining power. The vials are overfilled so you can get more EPO out of a multi-dose vial than is on the label.
Iron and EPO work together and if a patient is iron deficient, the EPO won’t work as well. Facilities are reimbursed for IV iron too so there is no disincentive to provide it. Some facilities don’t want their home patients to self-administer IV iron because the companies that make it warn of the risk of allergic reaction and patients or their families could sue if a problem occurred. Problems are rare though and some clinics take the risk to save their patients the inconvenience of having to come to clinic for IV iron, which is especially hard for patients that work or who live a long way from the clinic. Some doctors prescribe oral iron for their home patients (and their center ones too) which may not be as effective in renal patients due to poor GI absorption.
The only new policy I know about is that providers now need to say whether they’re giving a patient EPO subcutaneously or by IV. Some patients don’t like the extra needle stick, but some research has shown that EPO is at least as effective if not more effective when given subq. I assume that CMS (Medicare) is going to collect data for a while and see whether it does make a difference in how much EPO is needed to keep the H/H in the target range which is 11-12.
Section 60 in the Medicare Claims Processing Manual discusses how a facility must bill for EPO and other separately billable drugs.
BTW, there are other things that can reduce the effectiveness of EPO besides iron deficiency, like inadequate dialysis, infection, inflammation, cancer, malnutrition, etc. It’s important for providers to assure that patients don’t have or that they treat any of these conditions to make sure that EPO is as effective as possible.
There may be other changes in the future because there is an FDA meeting 9/11 to review EPO. Medicare wants to save money on this expensive drug. I don’t oppose being as cost effective as possible. However, I do hope that patients won’t suffer because of any future policy change. There have been reimbursement changes in the past that negatively impacted patients’ functioning.
[QUOTE=Beth Witten MSW ACSW;14360]Over the years, Medicare has changed the rules many times regarding when to start, stop, hold, cut doses, how to bill, how much is reimbursed, etc. for EPO. EPO is an expensive drug. Medicare reimburses for EPO at pretty much what providers pay for it assuming the bottle held the amount it says it holds. Medicare pays for the syringe to administer it. Medicare doesn’t pay for the time to administer it. There is a profit in it for LDOs (large dialysis organizations) because they can bulk buy EPO and get better prices from Amgen based on quantity. Small providers pay more for it because they don’t have the bargaining power. The vials are overfilled so you can get more EPO out of a multi-dose vial than is on the label.
.[/QUOTE]
Beth, it makes no sense that MSN reimburses what the provider pays, or what they say they pay. In checking my MSN claims on MyMedicare website, I see that although the provider was paid $179 as the composite rate for the treatments, they also paid $18000 for four vials of 100mcg of Aranesp. I complained to the provider in the past for the outrageous billing. When ordering 4 syringes from Drugstore.Com, each is approximately $500. How can the provider get away with billing $4500, and getting it.
The 200mcg’s I got last Saturday were about $1000 each; about the same as the website.
With all of the controversy about ESA’s, bundling, etc, one would think that our bureauocratic government would have better control over a drug where there is so much activity. Hey, maybe if they had better control over the costs and consistent reimbursement, the issue of bundling maybe wouldn’t even be necessary.
[quote=Jane;14356]Beth,
I meant I did not get any EPO last week, because they failed to give it to me due to their new policy. Rather than giving it to me at my monthly visit to take home with me ( I give it at home ), they told me it would be mailed to me for now on. So I totally missed getting EPO last week. I thought this new policy might be Medicare related. What other reason would there be for EPO being mailed?[/quote]
Now this is first time I hear this! I too take EPO viles home from clinic…I self administer EPO and supplies including the 1cc needles are given to me on a monthly basis.
I don’t understand why they would mail it to you? Could it be a cost saving policy? Anyway, I will sure ask about this at my clinic…
[QUOTE=Beth Witten MSW ACSW;14360]Over the years, Medicare has changed the rules many times regarding when to start, stop, hold, cut doses, how to bill, how much is reimbursed, etc. for EPO. EPO is an expensive drug. Medicare reimburses for EPO at pretty much what providers pay for it assuming the bottle held the amount it says it holds. Medicare pays for the syringe to administer it. Medicare doesn’t pay for the time to administer it. There is a profit in it for LDOs (large dialysis organizations) because they can bulk buy EPO and get better prices from Amgen based on quantity. Small providers pay more for it because they don’t have the bargaining power. The vials are overfilled so you can get more EPO out of a multi-dose vial than is on the label.
Iron and EPO work together and if a patient is iron deficient, the EPO won’t work as well. Facilities are reimbursed for IV iron too so there is no disincentive to provide it.
What I have experienced is, IV iron is not given in accordance with dropping iron sat. DOQI recomends an iron sat of at leaste 25. Iron isn’t given when it should be, so then more EPO is required to keep patients’ H/H up. I’m asking do you think this is purposeful or not? Also, what level of profits do clincs make off of EPO and IV iron. Because if they were dishonest, couldn’t they increase the profits in this way?