Download ProCare HospiceCare Medicare Part D and the Hospice Patient

ProCare HospiceCare
Written by Clinicians, for Clinicians
Summer 2011 Edition
Medicare Part D
and the Hospice Patient
Victoria Ferraresi, PharmD, FASHP, FCSHP Director of Pharmacy Services at Pathways Hospice, Sunnyvale, California and Clinical Pharmacist, ProCare HospiceCare Ensuring that pharmacies properly process prescription claims for
medications can be an ongoing problem for hospice programs.
Pharmacies may process claims for hospice-covered medications
through a beneficiary’s Medicare Part D plan rather than through
the hospice program prescription plan. Sometimes patients want
to continue with previous insurance in order to get a larger supply
of medication. The community pharmacist may not realize the
patient is enrolled in hospice or they may be unfamiliar with how
to bill via the hospice prescription plan. Patients residing in
facilities are especially likely to experience this, as medications are
delivered to the facility and billed to the patient at a later date,
with nobody present at the pharmacy to question why the billing is
incorrect or a copayment is being collected.
The Medicare Part D Billing Manual clearly states that a medication
covered under Part A (for example by hospice) is not eligible for
coverage under Part D:
20.2 - Drugs Covered Under Medicare Part A or B
(Rev. 2, Issued: 07-18-08; Effective/Implementation
Date: 07-18-08)
Part D specifies that a drug prescribed to a Part D eligible
individual cannot be considered a covered Part D drug if
payment for such drug “...is available (or would be available but
for the application of a deductible) under part A or B for that
individual. ”CMS interprets this to mean that if payment could
be available under Part A or Part B to the individual for such
drug, then it will not be covered under Part D…1
On February 18, 2011, CMS published “Advance Notice of
Methodological Changes for Calendar Year (CY) 2012 for Medicare
Advantage (MA) Capitation Rates, Part C and Part D Payment
Policies and 2012 Call Letter.”2 This notice clarifies and reminds
Part D providers that medications covered by a hospice program
(Continued on page 3)
HospiceCare 2020
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So far this year we have visited three
cities and the response from
participants has been overwhelming.
Attendee evaluations include:
Ketamine Information for Neuropathic Cancer Pain Clinical Use By Gerard M. McKeegan, Clinical Pharmacist, ProCare Hospice Care Ketamine is a short acting anesthetic agent that has analgesic properties at sub‐anesthetic doses. A synergistic effect between ketamine and opioids has been observed in patients who have lost an analgesic response to high doses of morphine. Ketamine is usually used in pain that has failed to respond fully to opioids despite escalating doses and combination with appropriate adjuvants. It may be particularly helpful in neuropathic pain. Mode of action Various mechanisms have been proposed to explain the analgesic effect of ketamine. The effect seems to be mediated in part through inhibition of N‐methyl‐D‐aspartate (NMDA) receptors. Ketamine also interacts with cholinergic and opiate receptors and possibly inhibits the synaptic re‐uptake of monoamines. Formulation Ketamine can be administered orally, or by subcutaneous or intravenous infusion. Starting oral Ketamine 1. If the patient is already taking an opioid a dose reduction should be considered e.g. up to 30 to 50% dose reduction. 2. A typical starting dose of oral Ketamine is 10 to 25mg every 8 hours. 3. Consider the use of oral haloperidol 2‐5mg at night or oral diazepam 5mg for neuropsychiatric side effects. 4. Doses are usually increased in steps of 10 to 25 mg per dose every 3‐4 days until the desired dose is reached up to a usual maximum of 50mg every 6 hours (maximum reported dose 200mg every 6 hours). 5. Titrate the opioid dose down further if possible 6. If pain is returning before the next dose is due the dosing interval can be shortened to every 4‐6 hours. Preparation of Ketamine Oral Solution The only commercially available formulation of Ketamine is an injection (50mg/mL and 100mg/mL multidose vials). To prepare a 100 ml oral solution of Ketamine (10 mg/ml): 1. Dilute a 10 ml vial of Ketamine labeled 100mg/ml with 90 ml of diluent (water and/or Cherry Syrup or other such flavoring). Final product concentration will be Ketamine 1000 mg/100 ml or 50 mg/5 ml. 2. Store in the refrigerator with an expiration date of 7 days from compounding date. 3. Ketamine Oral Solution may have a bitter taste if flavoring not used but each dose may be disguised in juices such as orange juice and cola drinks. Starting Parenteral Ketamine Injection 1. For IV analgesia: usual starting dose IV is 0.1 mg/kg/hr or about 5 mg/hr. This dose can be increased by 1‐2 mg q 2 hr to achieve better pain management. The usual maximum dose for analgesia in the literature is 20‐
25 mg/hr. 2. If the patient is already taking an opioid a dose reduction might be considered. e.g. up to 30 to 50% dose reduction. 3. For Subcutaneous Infusion: The usual starting dose is 120 mg/24 hr or 5 mg/hr (Range: 50‐150 mg/24 hours). (Continued on page 4)
Medicare Part D and the Hospice Patient (Continued from cover page)
are not eligible for payment under a Part D plan (see page 85 in the CMS report) and that Medicare Part D
plans are sent beneficiary-level hospice data informing them of a beneficiary’s election of the MediCare
Hospice Benefit: Preventing Part D Payment for Hospice Drugs
Hospice programs, as specified in section 1861(dd) of the Social Security Act and in Federal
regulations at Part 418, must provide individuals under hospice care with drugs and biologicals related
to the palliation and symptom management of the terminal illness as defined in the hospice plan of
care. The only drugs covered by the hospice program are those used primarily for relief of pain and
symptom control related to the individual‘s terminal illness. However, because hospice care is a
Medicare Part A benefit, the drugs provided by the hospice and covered under the Medicare per-diem
payment to the hospice program are not covered under Part D.
Our October 23, 2010 memorandum entitled, ―Preventing Part D Payment for Hospice Drugs,
incorrectly stated that all Part D sponsors currently do not have the ability to identify any Medicare
enrollees who have elected hospice. In fact, CMS has been sending beneficiary-level hospice
data to all Part D sponsors. These data are currently sent on the transaction reply report
(TRR) at the time of the beneficiary‘s enrollment and subsequently whenever the hospice
86 information changes. As specified in the Plan Communications User Guide, the TRR
includes a hospice indicator in position 54 and, in positions 85-96, a hospice start date
and, if applicable, hospice termination date. The associated transaction reply codes are
071- Hospice status set and 72- Hospice status terminated. Sponsors need to ensure their
claims processor is notified of an enrollee‘s hospice election and that processes are in place to prevent
Part D payment for hospice drugs.
Beginning in 2007, the Office of the Inspector General (OIG) included the issue of patients utilizing both drug
plans in their annual Work Plan, which describes specific area of focus for their investigative activities into
fraud and abuse.3
Medicare Part D Administration - Dually Eligible Hospice Patients
We will determine the propriety of drug claims for individuals that are receiving hospice benefits under
Medicare Part A and drug coverage under Medicare Part D. CMS established daily per diem rates to pay
for hospice benefits, which include prescription drugs (used for pain relief and symptom control) related
to the beneficiary’s terminal illness. Hospice providers are paid daily per diem amounts, which include
drugs related to a hospice beneficiary’s terminal illness. Medicare Part D, which began January 2006,
covers prescription drugs for Medicare beneficiaries enrolled in this voluntary benefit. Because the
hospice program continues to cover prescription drugs related to a hospice beneficiary’s terminal illness,
Medicare Part D drug plans may unknowingly duplicate payments for prescription drugs related to a
hospice beneficiary’s terminal illness. We will identify whether this is a widespread problem and, if so, the
controls needed to prevent duplicate drug payments.
(OAS; W-00-07-35307; various reviews; expected issue date: FY 2007; new start)
It has been included it in every yearly OIG Work Plan since then.4-7
In light of the regulatory scrutiny focused on hospice programs via OIG, RACs (Recovery Audit Contractors),
ADRs (Additional Documentation Requests), etc., hospices should make sure that claims for hospice-covered
medications are being properly billed via the hospice pharmacy plan and that they document patient education
in this area.
ProCare HospiceCare can assist by providing reports (look for patients with no prescription claims), reversing
payment for improperly billed prescriptions, and in educating our pharmacist colleagues in this area.
Lorin: anything else we need to say here about our reports?
Ketamine Information for Neuropathic Cancer Pain (Continued from page 2)
4. Consider the use of diazepam 5 mg tid to control potential psychogenic side effects. 5. Titrate the opioid dose down further if possible. Note: Subcutaneous ketamine can be irritant and if used alone is probably best diluted with sodium chloride 0.9%. Changing patients from subcutaneous to oral Ketamine 1. The dose of ketamine orally is approximately half of that given subcutaneously. 2. Prescribe the appropriate oral dose in 3 divided doses. 3. For the first 24 hours continue the subcutaneous route but at 50% of the original dose 4. Increase the oral dose by 10‐25mg daily every 3‐4 days. 5. If pain is returning before the next dose is due the dosing interval can be shortened to every 4‐6 hours. Medicare Part D and the Hospice Patient (Continued from page 2)
References:
1. Medicare Prescription Drug Benefit Manual. Chapter 6 – Part D Drugs and Formulary Requirements.
www.cms.gov/manuals/downloads/Pub100_18.pdf. Accessed April 21, 2011.
2.
Blum J and Spitalnic P. Advance Notice of Methodological Changes for Calendar Year (CY) 2012 for Medicare
Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2012 Call Letter.
Centers for Medicare & Medicaid Services,Department of Health and Human Services.
www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Advance2012.pdf. Accessed April 17, 2011.
3.
Department of Health and Human Services. Office of Inspector General. Work Plan Fiscal Year 2007.
http://oig.hhs.gov/publications/docs/workplan/2007/Work%20Plan%202007.pdf. Accessed April 21, 2011.
4.
Department of Health and Human Services. Office of Inspector General. Work Plan Fiscal Year 2009.
http://oig.hhs.gov/publications/docs/workplan/2008/Work_Plan_FY_2008.pdf. Accessed April 21, 2011.
5.
Department of Health and Human Services. Office of Inspector General. Work Plan Fiscal Year 2009.
http://oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf. Accessed April 21, 2011.
6.
Department of Health and Human Services. Office of Inspector General. Work Plan Fiscal Year 2010.
http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf. Accessed April 21, 2011.
7.
Department of Health and Human Services. Office of Inspector General. Work Plan Fiscal Year 2011.
http://oig.hhs.gov/publications/workplan/2011/FY11_WorkPlan-All.pdf. Accessed April 21, 2011.
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Copyright 2011, ProCare Rx
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Editor: Dr. Lorin Yolch, PharmD
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