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Responding to the Cures Act Pricing Changes for Home Infusion Drugs

Written by: Mediware Bloggers on Monday, February 13, 2017 Posted in: Home Infusion

By: Jeanne Lugli, General Manager, Mediware Reimbursement Services

As we discussed in last week’s blog post, as a result of the 21st Century Cures Act, average sales price (ASP) reimbursements went into effect for Part B covered infusion drugs starting on January 1, 2017.

You may recall that there was talk about ASP pricing implementation for quite some time. In fact, it was on the list of offsets for the Cures Act as far back as 2015. However, the reduction from AWP to ASP was supposed to be accompanied by a “services payment provision” that was:

  • Built off of the Medicare Home Infusion Site of Care Act
  • Applicable only to Part B DME infusion drugs

Unfortunately, while ASP based pricing is now in effect, the service component is not scheduled to go into effect until January 1, 2021! The National Home Infusion Association (NHIA) is aggressively fighting to have the ASP provision reversed until the service component can be implemented. However, changes to Medicare fee schedules are only made on a quarterly basis. Thus, if we are successful in reversing this pricing, the earliest date that it can be implemented is April 1, 2017.  There is a glimmer of hope that change may occur given the recent delay of the next round of competitive bidding.

In the interim, there are several drugs that will be greatly impacted. There are also a few that have an increase in rate, but that is the exception more than the rule. In trying to evaluate the potential loss in revenue, we have made some general assumptions based on the last published ASP for a particular drug.

For example, Milrinone 0.2mg/ml (J2260) had an ASP of $3.43 in Q4 2015. Thus, we can assume that the rate will be somewhere in that ballpark; however, it certainly could be different. Also, as a point of reference, the current allowable for J2260 (based on AWP) is approximately $51.00/unit. (The allowable varies by state.) This is by far the biggest discrepancy in moving to an ASP model.

What can you do right now?

  1. If you provide any Part B drugs, we recommend that you do an analysis of your cost compared to the new rates.
  2. Determine the feasibility of continuing to service or transition these patients if your business model will allow.
  3. If you opt to continue to service these patients, it’s critical that you capture the cost of servicing them. NHIA is looking to all providers to supply solid data for the cost of servicing patients receiving Part-B-covered drugs in the home because this information will help justify the “services payment provision” when it is implemented.
  4. Continue to reach out to your local senators to lobby for appropriate fees to service these patients, some of whom are on life-sustaining medications, in home settings.
  5. Reach out to Mediware Reimbursement Services directly to discuss the impact to your business and ways that MRS can help you manage the change from AWP to ASP pricing.

Mediware Reimbursement Services, the experts in home infusion billing, can help by determining the impact of ASP pricing on your business and maximizing your infusion reimbursements. You have to live with these changes for the next three months at a minimum, so let’s find a way to make it work.