Like us on Facebook

CAMPS Events & Education


FIND YOUR FEDERAL REPRESENTATIVE HERE
California HME Update

DHCS Announces Medi-Cal Pharmacy Claw Back For Non-Chain Pharmacies   
 
DHCS has published a notice on the Provider Home Page indicating that non-chain pharmacies could begin seeing claw back of payments as early as 1/14/16. They have completed the reprocessing of all impacted claims for all pharmacy providers and now will begin recoupment of 5% in an individual check write. We have printed the notice below. There is no indication as of yet on the timing for the claw back for DME. As we indicated in prior notices an impacted pharmacy provider can ask to have the 5% recoupment amount reduced based upon hardship.  You need to contact Xerox for any hardship exemption or changes.

Ten Percent Payment Reduction and Recoupment 
for Pharmacy Claims
December 28, 2015

Assembly Bill 97 (Chapter 3, Statutes of 2011) requires the Department of Health Care Services (DHCS) to implement payment reductions of up to 10 percent to most categories of service in the Medi-Cal program, including pharmacy services.

On February 7, 2014, DHCS implemented prospective payment reductions for pharmacy claims with dates of service on or after June 1, 2011. On August 24, 2015, DHCS began the process of retroactively reprocessing pharmacy claims subject to AB 97 reductions.

DHCS originally planned to begin recoupment activities approximately two weeks after each individual pharmacy provider's claims were completely reprocessed. However, since communicating this plan, DHCS has opted to allow pharmacy providers additional time from when a provider's claims are reprocessed to when the actual recoupment occurs.

As of December 10, 2015, all pharmacy claims subject to AB 97 payment reductions have been reprocessed by DHCS. Additionally, providers should expect to see recoupments from future warrants beginning as early as the January 14, 2016 warrant date. Providers may view the checkwrite schedule in the Checkwrite section of the Part 1 provider manual.
 
 
CMS Posts Regulatory Notice To Expand Medicare Prior Authorization Process       

CMS has posted a notice of intent to expand the current prior authorization process to include other items of DME and respiratory equipment that has a purchase price that exceeds $1,000 or $100 per month in rental reimbursement. CMS claims that the prior authorization process will not alter current coverage policy but require the provider to submit coverage documentation earlier in the process. Here is a link to the CMS press release that describes the regulatory package that details the expanded prior authorization process
 
The regulation package published on 12/30/15 is effective in 60 days and requites CMS to create a Master List of 135 items on the Medicare DME fee schedule that meet the financial requirements described above. An item of DME that is placed on the list does not automatically mean that it will be subject to prior authorization. Obviously a lot more operational details will be forthcoming the next 60 days.
  




One Capitol Mall, Suite 800
Sacramento, CA 95814 
t: (916) 443-2115 
f: (916) 444-7462