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Physicians must enroll in Medicare or opt-out by June 1, 2015, in order to prescribe drugs covered by the Medicare Part D prescription drug program, according to new federal regulations.
The final rule, released on May 19, outlines changes to the Medicare Advantage and Part D prescription drug programs for 2015.
Officials at the Centers for Medicare & Medicaid Services said they moved forward with the plan to require physician enrollment after reports that unqualified individuals were prescribing Part D drugs, including some physicians with suspended licenses.
Under the rule, physicians and other prescribers must enroll in the Medicare program or have a valid opt-out affidavit on file with a Part A/Part B Medicare Administrative Contractor by June 1, 2015. CMS will not pay for drug claims that do not have a National Provider Identifier on the claim.
CMS had originally proposed that physicians and other prescribers enroll by Jan. 1, 2015, but decided to offer more time because the earlier date would not have given physicians or the agency adequate time to prepare.
The Affordable Care Act already requires physicians and other providers to enroll in Medicare if they order durable medical equipment, prosthetics, orthotics and supplies, or if they certify home health care for Medicare beneficiaries.
The final rule also aims to crack down on improper prescribing by threatening to kick physicians and other providers out of the Medicare program if they display a pattern of "abusive" prescribing or if their prescribing patterns pose a "threat to the health and safety of Medicare beneficiaries" or both.
The agency did not provide a definition of those terms, stating that it needed flexibility to implement the new policy.
But they outlined criteria that will be used when assessing prescribing patterns. Here are some of the questions that CMS will ask:
- Are there diagnoses to support the indications for which the drugs were prescribed?
- Was the patient deceased or out of state at the time of an alleged office visit?
- Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?
- Has the physician been subject to disciplinary actions by the state medical board?
- Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?
- Has a public insurance program restricted or revoked the physician's prescribing privileges?
CMS can also remove physicians from Medicare if the physician's Drug Enforcement Administration Certificate of Registration is suspended or revoked, or the state licensing body has been suspended or revoked their prescribing authority.
But CMS will revoke Medicare enrollment for prescribers only in "very limited and exceptional circumstances," agency officials wrote in the final rule. And, as a result, they wrote that they don't expect the new rule to have a chilling effect on prescribing activities or to impact access to medications.
Information on the Medicare enrollment process and the timeframes for processing applications is available on the CMS website.
mschneider@frontlinemedcom.com
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