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Breaking News_IACP Submits Comments to CMS on Billing Issues
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IACP Submits Comments to CMS on Equality in Billing of “Prepared Drugs”

09/14/2012 -- For more than a year, IACP’s Work Group on Centers for Medicare and Medicaid Services (CMS) Billing Issues has developed positions and policies for the Academy’s Board of Directors on how pharmacies are supposed to submit bills for “prepared drugs” compounded and dispensed incident-to a billable physician service. Last week, your Academy submitted formal comments to proposed rules issued by the agency.

According to the agency, only physicians who administer a medication in their offices are permitted to directly bill or be reimbursed for those products. Where that impacts pharmacists – and compounders especially – is when a medicine is prepared by the pharmacy but administered in the physician’s office. According to CMS, the pharmacy should only bill and receive payment for those preparations from the prescriber and not CMS directly.

At the heart of the issue is a serious inconsistency in CMS’ policy and its enforcement of that position. Some of the regional carriers – the companies hired by CMS to process Medicare billings -- have accepted and paid for direct pharmacy billings for “prepared drugs.” Other carriers around the country have not. That has created an unlevel playing field for pharmacies that are unable to compete equitably in the marketplace. Some pharmacies regions with carriers that pay directly have used that as a marketing tool to secure business from other pharmacies.

“IACP has looked at this imbalance cause by CMS and tried to find the right middle-ground,” says IACP Immediate Past President John Herr, RPh, FIACP. “The difficulty is that we have some members who are helped and some who are harmed by the agency’s failure to solve the problem of their own making. In preparing our comments, we focused on how this will be resolved now and prevented in the future rather than saying that one group is right and one group is wrong.”

“This issue will not be fixed any time soon,” says IACP Vice-President of Government Affairs Sarah Dodge. “At a minimum, CMS will take several months to read through all the comments on this important compounding issue before it makes any further decision. Plus, we have to understand that our issue is but three pages within a much larger rule making publication which affects everything from this problem to the new reimbursement structure for physicians.”

As things develop IACP will continue to update you on our efforts to secure fair treatment for compounders by public and private payers.

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