RE: re: Payment for immunos

[Guest guest]

You have to remember the immunos are processed under Part B by Medicare as a

medical claim, not as a prescription. So, that 20% should be paid by the pt's

secondary ins as a medical claim (as if they were paying for a MD visit, x-ray,

blood work, etc), not under their drug benefit. So, if the Keystone HPE is

paying for balances after Medicare Part B services, that's where the immunos

should be falling under.

________________________________

From: TxFinancialCoordinators on behalf of Lovely, Janet M.

Sent: Fri 1/15/2010 10:16 AM

To: TxFinancialCoordinators

Subject: re: Payment for immunos

Has anyone had a problem with pharmaceutical firms like Express Scripts refusing

to pay secondary to Part B Medicare for immunos? (The patient has Medicare and

Keystone HPE, which refuses to pay for medications.)

If so, has anyone found a creative solution?

I have been told that there could be an audit at a later date if the patient

bypasses Medicare and that the pharmacy could reclaim their money, because

technically, Medicare should have paid as primary.

It seems unfair to me to ask the patient to pay 20% when they have other

coverage.

Thanks for your input.

Janet M. Lovely

Lankenau Hospital

Phila., PA

[Guest guest]

That is correct , the nuances of the medical benefit vs the pharmacy benefit causes much of this confusion.Sent from my iPhoneYou have to remember the immunos are processed under Part B by Medicare as amedical claim, not as a prescription. So, that 20% should be paid by the pt's secondary ins as amedical claim (as if they were paying for a MD visit, x-ray, blood work, etc), not under their drug benefit. So, if the Keystone HPE is paying for balances after Medicare Part B services, that's where the immunos should be falling under. From: TxFinancialCoordinators on behalf of Lovely, Janet M.Sent: Fri 1/15/2010 10:16 AMTo: TxFinancialCoordinators Subject: re: Payment for immunos Has anyone had a problem with pharmaceutical firms like Express Scripts refusing to pay secondary to Part B Medicare for immunos? (The patient has Medicare and Keystone HPE,which refuses to pay for medications.)If so, has anyone found a creative solution? I have been told that there could be an audit at a later date if the patient bypasses Medicare and that the pharmacy could reclaim their money, because technically, Medicare shouldhave paid as primary. It seems unfair to me to ask the patient to pay 20% when they have other coverage. Thanks for your input. Janet M. LovelyLankenau HospitalPhila., PA

[Guest guest]

Generally I have found the such as Express

Scripts or Medco do not work with Medicare B – so for the immunos our patients

keep these as a retail pharmacy that does work with Medicare B -- meds are

gotten 30-days at a time.

Daryl Battin,

MSW/LICSW

Financial

Coordinator/Social Worker

Department of

Transplantation -- Kidney

Lahey Clinic, 41 Mall Road, Burlington

MA 01805

Ph:

/ FAX:

Page:

From:

TxFinancialCoordinators

[mailto:TxFinancialCoordinators ] On Behalf Of Fox

Sent: Friday, January 15, 2010

11:34 AM

To:

TxFinancialCoordinators

Cc:

TxFinancialCoordinators

Subject: Re:

re: Payment for immunos

That is correct , the nuances of the medical benefit vs the

pharmacy benefit causes much of this confusion.

Sent from my iPhone

On Jan 15, 2010, at 9:32 AM, " Aguiar, " <laguiarwkhs> wrote:

You have to remember the immunos are

processed under Part B by Medicare as a medical claim, not as a

prescription. So, that 20% should be paid by the pt's secondary ins as a medical

claim (as if they were paying for a MD visit, x-ray, blood work, etc), not

under their drug benefit. So, if the Keystone HPE is paying for balances

after Medicare Part B services, that's where the immunos should be falling

under.

From: TxFinancialCoordinators

on behalf of Lovely, Janet M.

Sent: Fri 1/15/2010 10:16 AM

To: TxFinancialCoordinators

Subject:

re: Payment for immunos

Has anyone had a problem with

pharmaceutical firms like Express Scripts refusing to pay secondary to Part B

Medicare for immunos? (The patient has Medicare and Keystone HPE, which

refuses to pay for medications.)

If so, has anyone found a creative

solution?

I have been told that there could be an

audit at a later date if the patient bypasses Medicare and that the pharmacy

could reclaim their money, because technically, Medicare should have paid as

primary.

It seems unfair to me to ask the patient

to pay 20% when they have other coverage.

Thanks for your input.

Janet M. Lovely

Lankenau Hospital

Phila., PA

See our web page at http://www.lahey.org for a full directory of Lahey sites, staff, services and career opportunities.

THIS MESSAGE IS INTENDED FOR THE USE OF THE PERSON TO WHOM IT IS ADDRESSED. IT MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. If you are not the intended recipient, your use of this message for any purpose is strictly prohibited. If you have received this communication in error, please delete the message and notify the sender so that we may correct our records.

[Guest guest]

Thanks.

I agree that Keystone should pay as secondary, but they are standing firm that they will not cover these meds unless they are injectibles. I spoke with a representative and they confimred with two technical advisors. I will call back and ask for a supervisor.

From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Aguiar, Sent: Friday, January 15, 2010 11:31 AMTo: TxFinancialCoordinators Subject: RE: re: Payment for immunos

You have to remember the immunos are processed under Part B by Medicare as a medical claim, not as a prescription. So, that 20% should be paid by the pt's secondary ins as a medical claim (as if they were paying for a MD visit, x-ray, blood work, etc), not under their drug benefit. So, if the Keystone HPE is paying for balances after Medicare Part B services, that's where the immunos should be falling under.

From: TxFinancialCoordinators on behalf of Lovely, Janet M.Sent: Fri 1/15/2010 10:16 AMTo: TxFinancialCoordinators Subject: re: Payment for immunos

Has anyone had a problem with pharmaceutical firms like Express Scripts refusing to pay secondary to Part B Medicare for immunos? (The patient has Medicare and Keystone HPE, which refuses to pay for medications.)

If so, has anyone found a creative solution?

I have been told that there could be an audit at a later date if the patient bypasses Medicare and that the pharmacy could reclaim their money, because technically, Medicare should have paid as primary.

It seems unfair to me to ask the patient to pay 20% when they have other coverage.

Thanks for your input.

Janet M. Lovely

Lankenau Hospital

Phila., PA

[Guest guest]

,

Is there a known law that says insurance

companies have to consider immunos a major medical expense just because

Medicare does (when commercial is secondary)?

I have found that most insurance companies

refuse to cover the 20% coinsurance for immunos as a major medical expense

secondary to Medicare. In these cases, we do encourage the patients to

get their immunos through their prescription drug plan. The commercial drug

plans are aware that the patient has Medicare and do allow patients to use this

benefit for their immunos.

Thanks!

Amy Murray, Transplant Financial Coordinator

Via Christi Regional

Medical Center

929 N. St. Francis, Ste. M157 • Wichita KS 67214

Phone: (316) 268.8295 •

Fax: (316) 291.7765

amy_murray@...

From:

TxFinancialCoordinators

[mailto:TxFinancialCoordinators ] On Behalf Of Fox

Sent: Friday, January 15, 2010

10:34 AM

To:

TxFinancialCoordinators

Cc:

TxFinancialCoordinators

Subject: Re:

re: Payment for immunos

That is correct , the nuances of the medical benefit vs the

pharmacy benefit causes much of this confusion.

Sent from my iPhone

On Jan 15, 2010, at 9:32 AM, " Aguiar, " <laguiarwkhs> wrote:

You have to remember the immunos are

processed under Part B by Medicare as a medical claim, not as a

prescription. So, that 20% should be paid by the pt's secondary ins as a medical

claim (as if they were paying for a MD visit, x-ray, blood work, etc), not

under their drug benefit. So, if the Keystone HPE is paying for balances

after Medicare Part B services, that's where the immunos should be falling

under.

From: TxFinancialCoordinators

on behalf of Lovely, Janet M.

Sent: Fri 1/15/2010 10:16 AM

To: TxFinancialCoordinators

Subject:

re: Payment for immunos

Has anyone had a problem with

pharmaceutical firms like Express Scripts refusing to pay secondary to Part B

Medicare for immunos? (The patient has Medicare and Keystone HPE, which

refuses to pay for medications.)

If so, has anyone found a creative solution?

I have been told that there could be an

audit at a later date if the patient bypasses Medicare and that the pharmacy

could reclaim their money, because technically, Medicare should have paid as

primary.

It seems unfair to me to ask the patient

to pay 20% when they have other coverage.

Thanks for your input.

Janet M. Lovely

Lankenau Hospital

Phila., PA