Washington Agenda

MGMA Connexion, Jul 2006

What MGMA is doing as your advocate

* The Medical Croup Management Association (MCMA) has worked closely with a group of Medicare Part D stakeholders to develop a common form for providers to use when requesting exceptions to Part D drug formularies. Download the "Request for Medicare Prescription Drug Coverage Determination"form by going to the Medicare Part D Resource Center in the member area of mgma.com.

The form is intended to simplify requests for prior authorizations and coverage for nonformulary drugs. This form does not allow providers to request an exception to Medicare Part D drug formularies if they seek coverage of biotech or other specialty drugs; the Centers for Medicare & Medicaid Services (CMS) still requires drug-specific forms for that purpose. Currently, health plans can adopt this form voluntarily; America's Health Insurance Plans (AHIP) has stated that a number of carriers will use it immediately. CMS considers use of the form a "best practice" and says that it, or something similar, will eventually become mandatory.

If a provider receives a returned standard form, he/she should notify the CMS' Physician Regulatory Issues Team (prit@cms.hhs.gov) via e-mail. The standard form, along with all health-planspecific appeals and exceptions requests, follows a strict timeline. Health plans have 24 to 72 hours for expedited requests - from the time CMS receives them - to respond to a provider or advocate regarding documents.

* CMS regional offices have offered varying opinions on the proper procedures for billing consultations, which resulted in MGMA raising members'concerns with the Physician Regulatory Issues Team (PRIT), a CMS group charged with reducing the regulatory burden on physicians. In December 2005, CMS changed the Medicare consulting billing guidelines in Transmittal 788 (change Request 42115) to clarify that the ordering physician must document the request for consultation before the consulting physician can bill for the service. On April 18, 2006, PRIT stated that it does not expect the consulting physician to verify that the ordering physician has documented the consultation request in the patient chart.