Are you Billing Medicare Part B for Blood Glucose Testing Supplies and other items that are refilled on a recurring basis?
If you are, Medicare has some new rules and clarifications for some older ones. These apply to ALL suppliers, whether accredited or not.
Contact between the Supplier and Beneficiary
The new Medicare compliance for refills mandates that pharmacies are required to contact the beneficiary or designee regarding refills prior to providing the refills and must not automatically dispense the refill on a pre-determined basis. In essence, pharmacies must not send refills without a request for a refill from the beneficiary, as items without a valid document for a refill request will be deemed as unnecessary and unreasonable. The rule applies even if the automatic shipment for a refill has been authorized by the beneficiary.
The basis for formulating this rule stems from the need to ensure that the current supplies are diminishing and that the refilled item is necessary and reasonable. It also helps the beneficiary confirm any changes to the order, if necessary.
The contact rule in detail states that “contact must take place no sooner than 14 calendar days prior to the refill due date, and you may not dispense the item to the beneficiary sooner than 10 calendar days prior to the end of usage for the current product”. This is regardless of the delivery method.
When Do Suppliers Need A New Prescription?
Additionally, Medicare Compliance for refills requires a new prescription when:
- There is a change in the treating physician.
- There is a change of supplier.
- If the state law mandates that a prescription renewal is required.
- There is a change in the item(s), frequency of use, or amount prescribed.
- There is a change in the length of need or if a previously established length of need expires.
Maximum Refill Quantity
The regulations are not confined to when or how refill requests are fulfilled, but they also control the quantity of supplies. Suppliers must not provide a quantity of items that exceeds the quantity expected to be utilized by the beneficiary. In the event of an unusual change in the quantity or expected utilization, they must always verify the same with the physician. At any given time, pharmacies can dispense a refill quantity of no more than a one or three month period, regardless of the utilization.
Documentation for Refill Request
Medicare has also enacted new rules regarding “proof of refill request” for items that are going to be delivered to the beneficiary. We will see if the large mail-order entities follow this one. For these items, you need to document the request for refill either with a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary. The refill request must occur and be documented before shipment.
The Medicare compliance for refills requires that the refill record must include:
- Beneficiary’s name or authorized representative if different than the beneficiary
- A description of each item that is being requested
- Date of refill request
- Quantity of each item that the beneficiary still has remaining
For the “proof of refill request” for items that are going to be picked up at the pharmacy, the pharmacy only needs to obtain a signature from the beneficiary or caregiver that they have actually received the supplies.
This information (in addition to other Medicare required documentation) must be kept on file and be available upon request.
BE SURE to train your staff to make these requirements for Medicare compliance for refills a part of their daily tasks.