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Monday Jan 27, 2014

Wording of CMS Proposed Rule Causing Undue Angst About Medicare

proposed rule published Jan. 10 by CMS is expected to save the federal government $1.3 billion during a five-year period by curbing fraud, waste and abuse in the Medicare Advantage (Part C) and Medicare Prescription Drug Plan (Part D) programs.

Unfortunately, the wording of the 157-page regulation also created significant angst among some family physicians. Specifically, CMS wrote that it is proposing "to require that physicians or non-physician practitioners who write prescriptions for covered Part D drugs must be enrolled in Medicare for their prescriptions to be covered under Part D."

Some AAFP members who don't participate in Medicare have expressed concern that the proposed rule would affect their ability to prescribe medications for their Medicare patients, but that isn't the case.

"We believe that allowing opt-out physicians and eligible professionals to continue to prescribe covered Part D drugs to a Medicare enrollee would ensure consistency with the Part B program in this regard," the rule says.

In short, the requirement to enroll with Medicare is being confused with a requirement to participate with Medicare. Under this proposed rule, physicians still have the same three options regarding Medicare:

  • Physicians may sign a participating agreement and accept Medicare's allowed charge as payment in full for all of their Medicare patients.
  • They may elect to be non-participating physicians, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims.
  • They may opt out and become private contracting physicians, agreeing to bill patients directly and forgo any payments from Medicare to their patients or themselves. For example, if you are using the direct pay model of care, you still could do so without changing how you practice or bill. However, you will have to enroll in Medicare for your prescriptions to be covered by these plans.

The rule proposes that physicians and others prescribing drugs for Medicare patients be required to enroll so that CMS can "ensure that Part D drugs are only prescribed by qualified individuals." CMS implemented similar policy regarding durable medical equipment this month. The enrollment requirement actually will have no effect on most AAFP members because both participating and non-participating physicians are already required to enroll to bill for any Part B services that they provide. And, as stated above, CMS plans to continue to allow an option for physicians who opt out.

It is important to remember that this is a proposed rule, and it will not affect family physicians this year. The AAFP has not finalized our response to this proposed rule. Now is the time for you as members to provide the Academy with your thoughts and concerns to help us clarify our response during the comment period. You can do this in the comments area below.

In addition to the enrollment requirement, there are other provisions of this proposed rule the Academy will address. For example, the proposed rule requires formulary inclusion of all drugs within the antineoplastic, anticonvulsant and antiretroviral drug classes, but it no longer requires all drugs from the antidepressant and immunosuppressant drug classes to be included in Part D formularies.

The Academy is in the process of reviewing the proposed rule and will provide comments to CMS before the March 7 deadline. What are your thoughts?

Reid Blackwelder, M.D., is President of the AAFP.


I don't think that my angst is undue in the least. This proprosal is deeply disturbing. If this is adopted what will surely follow is that those who choose to be private contracting physicians will not be allowed to order diagnostic studies for Medicare beneficiaries in the guise of fraud prevention. Furthermore, and more disturbing, I foresee that private insurance carriers will follow suit, bullying physicians into becoming network providers by prohibiting out-of-network providers from writing prescriptions. The Academy must forcefully and definitively draw a line in the sand in this instance.

Posted by keith dinklage on January 30, 2014 at 01:07 PM CST #

The rule proposes that physicians and others prescribing drugs for Medicare patients be required to enroll so that CMS can "ensure that Part D drugs are only prescribed by qualified individuals." Isn't that the function of my state medical board...to license "qualified individuals" and to ensure that medicne is practiced in accordance with the state law, specifically including the prescribing of pharmaceuticals. This is federal overreach plain and simple. I would think that we should be rattling sabers to fight this in court if necessary because it is a move to usurp a function that up until now has been specifically reserved to the states, as outlined by by the Tenth Amendment to the Constitution. I would urge in the strongest terms that we in medicine band together to fight against this move.

Posted by on January 30, 2014 at 03:09 PM CST #

After reading the ACA, (obamacare) it was obvious that the intent was the total control of the practice of medicine. This is another step in that direction. If allowed to proceed to its logical conclusion, the federal government will eventually have total control of your practice of medicine including licensing and how and probably where you can practice. I don't see organized medicine resisting these efforts on our behalf. Don't know how much longer I will continue to throw good money after bad by being a member. Sad--for us and our patients.

Posted by George McIlhaney on January 31, 2014 at 07:56 AM CST #

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