Monday, January 17, 2011

Medicare Part B

When I started at my current pharmacy, we had a certain physician who didn't want to cooperate and provide valid prescriptions for Medicare B covered items. Well maybe it wasn't the physician...the nurse would not let us speak to the physician to explain what we needed. The nurse would phone-in the orders for testing supplies and leave them on the voice mail.

Which would cause us to call back and say that phone-in orders are not valid for Medicare B diabetes supply claims. We would explain that we needed a hand-written or fax order that had:
  • the patient name
  • the product(s) being ordered
  • the quantity to be dispensed
  • the testing frequency
  • refill information
  • and the ICD coding appropriate for the patient's condition
You would think that we were asking them to fax over the patient's entire medical history in triplicate.

This went on for months. Patients were receiving substandard care because some nurse was having what she believed to be a turf issue. The last thing I want to do is keep a patient from being able to test their blood glucose levels, but I'm not going to circumvent the regulations that are in place.

I think it finally came down to one patient who was able to get the physician's attention on this matter. The patient asked me what I would do if I were in their shoes. I told them that if my physician wasn't willing to provide a valid prescription for my testing supplies, I would assume that they really didn't care about my condition and that I would change physicians. I handed the patient a leaflet that said what was required on the Medicare B prescriptions. The patient was on their way to the physician's office. I don't know the details of the conversation, but whenever we call now, we get what we need from that office.

We could have just fudged the information in the computer. Hope that we wouldn't get audited. Take care of the patient and not really worry about it. Good thing we didn't because...

We've been receiving Medicare B requests for additional information fairly regularly over the last few months. It's not too big of an issue because we follow the rules.

Most of the requests are for copies of the original prescriptions and signatures showing that they were picked up. That takes about five minutes to get together.

But then they want the pharmacy to provide copies of the testing logs and physician progress notes. That's a bit more time-consuming. Especially getting the physician notes. But we do it. And get it back to Medicare by the due date (which isn't too long).

The audit process wastes pharmacist time. Diverts pharmacist attention.

It makes me wonder if my pharmacy is being singled out, or are all Medicare B suppliers getting hit with audit requests. Given that Medicare has been burned by some of the fly-by-night businesses that bill for a couple million dollars of prosthetics, collect payment, then close up shop I can partially see the reason for auditing. But we only bill about 10 claims per week, and we have been doing this for years. It's not like we've suddenly quintupled the number of claims that we are submitting.

It also makes me wonder if Wilford Brimley and the folks over at Liberty Medical are being served with a proportionate amount of audits. Especially since I have had patients come in and tell me that they have over 1200 diabeetus test strips on hand because Liberty won't stop sending them.


Anonymous said...

Recently, I have had patients come in and tell me that they used to get their supplies from Liberty, and now they have to get them from another source?? I do not know why. I do know that the chain that I work for also has been getting more audits on Medicare B claims. We also have begun printing hard copy receipts which the patient signs on all Medicare B claims for testing supplies. We also are getting requests for testing logs. I had one patient new to Medicare on an Insulin pump. For that claim, I had to obtain, the make, model, and serial number for the pump, the date it was implanted, who paid for the pump, in addition to the signed prescription.

Anonymous said...

Thanks for the education. I don't think I was aware that the Rx's could not be supplied via phone. I only work occasionally, and it is difficult to keep up with all the rules. I don't think my area has been as extensively audited as yours because I haven't seen massive emails for cooperate regarding compliance.

However, I am often troubled by the fact that we are encouraged by cooperate to supply The ICD code if it is not provided by the prescriber. While I would love the have the authority to provide this code, I really do not think as a mere pharmacist under current State and Federal I can legally do this.

Also of note. In our local newspaper, there are adds by entities which will pay cash for unopened diabetes test strips.

pharmacy chick said...

interesting post. We no longer bill Medicare B. company decided to centralize it to one location nationally because of the audits and the chargebacks. I fought one auditor for months because he wanted to charge back on 600 strips. I had it all. The hard copy with ICD-9. Test 6-8 times a day. I had the sig log. she picked it up and signed for it. But when i had to fax 6 friggin months worth of testing logs ( 73 pages) he told me it didn't support the usage. The customer said. " I only have to write down 3-4 tests a day. I dont have to write down all 8 of them). " What right do they have to bring the patients compliance or non compliance as far as record keeping goes into whether we have the right to be paid for dispensing a proper rx. It just BURNS ME UP when I get these audit requests. Are we going to start seeing auditors telling us we have to see documentation that a patient has swallowed all of his pills at a certain date and time? why is this so different? I did write a blog post about this... last year I think...

Anonymous said...

I heard that Liberty is in trouble, and the patients are having to go elsewhere, but I don't know the details yet. We are getting more requests than usual as well for the Medicare B information.

JenRPh said...

I never understood why it was the responsibility of the pharmacy to supply testing logs or physician notes. Medicare should contact the patient and prescriber for that info or just refuse payment in the beginning.

rxcounter said...

I've had pts with thousands of extra test strips from Liberty too. Often they're coming in for a new meter because the shitty Liberty one stopped working right, or at all. Pretty bald-faced abuse on Liberty's part.

jmayfly said...

I wish the doctors were held more accountable for their prescribing of these supplies. As I understand it now, it all falls on the pharmacies to do all this extra work, and most doctors offices we deal with are not even aware there has been a change. We had our first Medicare B audit a couple weeks ago. Thank goodness my pharmacist is OCD about getting these done right. We got all our information together, except the testing log and physician notes. We then forwarded it via fax to the doctors office, with instructions to please finish the request with their info and fax it on. A few hours later, a new prescription is faxed to us for this patients test strips... I had a bad feeling about it, so I followed up with a call to the nurse. Apparently she didn't even read the nice big cover page attached to the 5+ pages we sent and thought we wanted a refill auth. When I pointed out over the phone the directions were on the cover page, she asked me if it was a HIPAA violation.
Wow, I think I rambled a bit...sorry folks.

lovinmyjob said...

It's my understanding that a phone-in order can be used for the FIRST fill of these supplies. We do this then fax a CMN to the doc AND give one to the patient. We explain that the next fill will not be covered by Medicare unless the doc fills this out and it is returned to us. Most of the time the patient can get the doc to take care of this before their next fill.

Anonymous said...

I work for a major chain/PBM (there is only one) and we unundated with Med B CMS audits on a daily basis. We cannot keep up with them and most of time is spent getting the information. physician progress notes, AOB, proof of delivery, shipping label, hard copy, testing logs, etc. I feel like I works for medical records rather than a pharmacy. It's getting quite ridiculous.

emilyivory said...

Comment 1


First of all, my comment is too long, so I am writing this in a couple comments with it labeled at the top. Sounds like you are all really good pharmacists...sure wish we had some that knew what they were doing where I live in Northern Michigan! I was hoping maybe you could help me with a problem I have been having trying to help my dad get his insulin for his insulin pump covered under Medicare part B. Any help would be appreciated as I have been to numerous pharmacies, on the phone with Medicare constantly, and scouring the internet for hours on end. Here is my problem:

I am having a super hard time trying to find the information I need about Medicare part B paying for the insulin that goes into my Dad's insulin pump. First off, my dad has been a Type I diabetic since he was 7 years old, and is now 56 years old. He has had an insulin pump for approximately 8 years, and my mom's blue cross coverage which is my dad's primary insurance provider, along with Medicare has paid for an insulin pump for my dad. For the past 6 years, my dad went to a local pharmacy, which sent their medicare claims out to a separate company, and then that company billed out the medicare for them. My dad's primary insurance provider would always cover approximately all the cost, except for $100, and then medicare always picked up the remaining $100. Recently however, the pharmacy where my dad took his prescriptions to, no longer sends their medicare billing to a different company to have them processed, and now the pharmacist can't figure out how to get medicare to pay the remaining $100. Is there a certain code they need to put into the computer to get it covered by Medicare Part B, and if so, do you happen to know that billing code so I can tell the pharmacist? I have also tried to take the prescription to a few other pharmacies with no luck as well. They either don't have the licensing to bill Medicare part B, or the pharmacist would be told by Medicare that because my dad has a primary insurance carrier, they won't cover anything.

emilyivory said...

Comment 2

Today, I called Medicare, and this is what I was told by them. Let's say for instance that Blue Cross covers 80% of what the cost of the insulin is, and Medicare says they pay 80% of what the cost of the insulin is as well. Medicare is telling me that since Blue Cross covers that 80%, that Medicare won't pay anymore because the 80% that Medicare would have paid is already being paid by another insurance provider. However, if for instance, Blue cross covered 50% of the cost of the insulin, and Medicare covers 80% of the cost of the insulin, Medicare MAY pick up the extra 30% that Blue cross doesn't pay to make it an 80% coverage. Kind of confusing, but I hope you understand what I am getting at. We just don't understand how for well over 6 or more years, Medicare part B picked up the remaining amount that my dad's primary insurance provider wouldn't pay, and now we can't get them to pay, or find a pharmacist who knows how to do so. It is very frustrating, and my dad can't afford the $100 a month deductible. My dad also told me that around 8 or more years ago, he was told by medicare that he won an appeal about his medical coverage, and that his insulin for his insulin pump would be completely paid for in full for the rest of his life. My mom is looking into finding the paperwork showing this, but until then, I was hoping you may be able to help us? I have paperwork from my dad's old pharmacy showing that Medicare did pay for the remaining amount that Blue Cross wouldn't pay, if that would be of any help to you, I could forward that information to you in a .pdf format to a specific email address if you would want to provide one.

Overall, is what Medicare telling me true, and if so, why would they cover the remaining amount before, and now they won't? Is there information I can tell a pharmacist to assist in getting this covered somehow? Your help is greatly appreciated, and thank you in advance for your help. If you have any questions, please feel free to email me at

Btw, we live in Michigan if the state we live in plays a factor in any of this!

Anonymous said...

The government has gone way too far in demanding testing logs from patients or anything from pharmacists or physicians. Ridiculous and invasive.

Susan said...

My pharmacist will not fill test strip precription unless im standing right there she says medicare requires that