MIPS and Medicare Part B Drugs – Waiting for the Other Shoe to Drop

by | Oct 10, 2017 | MIPS

We are whiling away the time today on a visit to the piedmont of North Carolina. Even though it is October it feels like the dog days of August. Humidity off the charts and I don’t even want to look at the temperature. What’s a poor boy to do?

I barely have the strength to raise the glass of lemonade to my parched lips. What little energy I have left only allows me to hit the “refresh” button on my computer browser about once an hour. What am I looking for? You know what it is. It is the Final Rule on the 2018 Updates to the Quality Payment Program (QPP). The proposed rule was published 6/30/2017 and then, of course, had to jump the “public comment period” hurdle and finally wind its way through the dark forest of bureaucracy. CMS sources tell us to expect the release no later than November 1, 2017.

I’m keeping my eyes open for the resolution of one pesky issue in the Final Rule due out in the next few weeks. It has the potential to rattle a few cages and aggressively impact the Medicare reimbursement of specialists in an unexpected way. We know that those Eligible Clinicians (EC) who will be impacted by MIPS will have their Medicare Part B charges affected. It also appears there is a strong possibility that their Part B drug charges will also be affected. These are drugs covered by Medicare Part B for, according to CMS, “a limited number of outpatient prescription drugs under limited conditions. Generally, drugs covered under Part B are drugs you wouldn’t usually give to yourself, like those you get at a doctor’s office or hospital outpatient setting.” These are often very expensive drugs and include those used in the treatment of such diseases as cancer and renal failure. Injected and infused drugs are included as well as those related to transplantation and osteoporosis. You can read more about these Part B drugs here.

Well, what about these Medicare Part B drug charges? Some specialists like oncologists, ophthalmologists, rheumatologists, dermatologists, and similar provides could find that all those Part B drugs could be impacted by their MIPS score. Instead of a 4% +/- adjustment in 2019 we could be looking at much higher reimbursement impact. The Proposed Rule states, “For Part B items and services furnished by a MIPS eligible clinician such as purchasing and administering Part B drugs that are billed by the MIPS eligible clinician, such items and services may be subject to MIPS adjustment based on the MIPS eligible clinician’s performance during the applicable performance period or included for eligibility determinations. For those billed Medicare Part B allowable charges relating to the purchasing and administration of Part B drugs that we are able to associate with a MIPS eligible clinician at an NPI level, such items and services furnished by the MIPS eligible clinician would be included for purposes of applying the MIPS payment adjustment or making eligibility determinations.”

You can imagine the public comments that have been submitted to undo this part of the Proposed Rule. There is a lot at stake here. Stay tuned and keeping hitting that “refresh” button on your browser. If you find yourself with nothing to do for the next few days you can go read the 1300 received public comments on the Proposed Rule.