PAAS Defends Community Pharmacies by Engaging DME Medicare Administrative Contractor CGS

Issue #1: DME MACs state corrections on an SWO must be signed off by prescriber

• Chapter 5.2.2 of the Medicare Program Integrity Manual states: “While the SWO has a limited number of required order elements, suppliers/providers are permitted to add elements that may provide clarity for issues such as length of need, frequency of use, dosage form/strength, refills frequency, etc. This additional information shall be corroborated by information in the medical record”
  • Section 5.2.2 does not state the prescriber must sign off on any additions or corrections to an SWO. This goes against standard pharmacy practice and conflicts with CMS guidance.

Issue #2: While refills are not a required element on the SWO, if the practitioner writes for refills, they will be honored exactly as specified regardless of the quantity dispensed

• Medicare allows the initial fill and as many times subsequently for the exact refills indicated on the prescription after which the prescription would be considered expired
• Example: A pharmacy receives an order for a 90-days supply, plus three refills (i.e., a full year’s worth of medication). If the pharmacy can only bill for one month at a time (Medicare requirement on most DMEPOS items), the pharmacy can only fill off this SWO for a total of 4 fills (likely 120 days), regardless of the total quantity written. Additional fills would be considered unauthorized refills and ineligible for reimbursement, despite standard pharmacy practice.
  • The DME MACs were unable to provide PAAS a citation or reference for their interpretation, stating they do not have the sophistication to track total quantity prescribed over the life of an SWO

Issue #3: OmniSYS memo – “An important Update About Medicare Part B Insulin Coinsurance Reductions and Deductible Waivers” when using insulin in a pump

• Section 11407 of the Inflation Reduction Act – The purpose of this Change Request (CR) is to implement the Medicare Part B deductible, which is waived for insulin furnished through an item of durable medical equipment and limits the beneficiary coinsurance for a month’s supply of insulin not to exceed $35. The supplier payment is to be adjusted “as necessary” so that Medicare pays for the rest of the amount for the month’s supply of insulin.
• As of July 1, 2023, suppliers billing between a 31 to 89-day supply or greater than a 90-day supply will continue to encounter days’ supply rejections.
• OmniSYS will automatically add the new JL or JK modifiers to claims billed as a 90-day supply
  • PAAS’s concern is that the claims processor is rejecting claims with a days’ supply of 31-89, interpreting the MLN literally for the JK and JL modifiers, which does not make sense for insulin being used in a pump. Rarely would the days’ supply work out perfectly to 30 or 90.

While the meeting with the nurse medical reviewers from both jurisdictions B and C at CGS was fruitless, we were able to escalate our concerns to the medical directors at CGS jurisdictions B and C. The directors were very open to discussion and receptive with our concerns regarding the SWO and OmniSYS issues discussed above. The directors have promised to forward our differing interpretations of section 5.2.2 to the CMS division of medical review and update us on any additional CMS guidance. PAAS will keep our members informed as things develop.