The National Association for Home Care & Hospice (NAHC) and its affiliated Hospice Association of America (HAA) wanted to provide an update on the Part D refund requests many hospices have received from PRS. As was reported at the end of May (see NAHC Report, May 27, 2014), many hospices were receiving refund requests for analgesics paid for by Part D for hospice beneficiaries in 2011 and 2012. Since that time NAHC and HAA have gained additional information that is of use and interest to hospices. NAHC and HAA will continue to investigate the requests and will provide updated information as it becomes available.
Below is what NAHC and HAA have learned thus far:
Optum Rx is a pharmacy benefits manager owned by United Health Group, which also owns United Healthcare.
1. Medications are not listed on the request letter, only Rx number. PRS has told NAHC and HAA that they cannot put the medication name in a letter due to privacy requirements. They are, however, working on developing a speadsheet that contains this information. That spreadsheet would be specific to each hospice and could be e-mailed to the hospice in a secure format. If the hospice is willing to receive the information this way PRS will send it.
UPDATE: NAHC and HAA does not have an anticipated completion date for these spreadsheets. NAHC and HAA have also heard that hospices can call PRS and obtain a list, but we've not been able to confirm this.
2. The total dollar amount listed in the body of the letter does not match the total computed when adding the dollar amounts listed with the Rx numbers. PRS is looking into this but could not explain that at this time.
UPDATE:PRS has indicated that the list of medications that each hospice owes has been broken down into batches of approximately 45 medications. The total dollar amount in the body of the letter, according to PRS, matches the total dollar amount owed by the hospice, which could be the total of several batches. Each batch of medications owed by the hospice will be sent to the hospice separately so hospices could be receiving multiple letters. At least two hospices have reported receiving more than one letter and the attachments are different. The total dollar amount owed by the hospice is tied to its PRS number. The PRS number is listed in the top left of the refund request letter.
3. The letter states that the hospice has 30 days from receipt of the letter (not the date of the letter) to file a dispute. Some hospices have been told that by filing a dispute they will not receive additional information. It is NAHC and HAA’s understanding that it will come from PRS - PRS will notify Optum Hospice Rx, which is PRS' customer - of the dispute and Optum Hospice Rx will decide the future course of action. We would like to have this information confirmed in writing from PRS but we do not have that at this time.
UPDATE: Neither PRS nor Optum nor United Healthcare is able to indicate what the next course of action will be in collection efforts. It is possible that there will not be any further action and it is possible that Optum/United will pursue this further. NAHC/HAA does not anticipate CMS getting involved further in this at this time as CMS instructed the plans to recover the money from the hospices without involving the pharmacies and we believe this to be the extent of CMS involvement at this time.
4. Hospices are reporting that they have been able to cross reference the Rx number and dollar amounts with invoices to figure out the exact medication. Upon doing so they realize that the hospice paid the pharmacy for the medication or told the pharmacy to bill them and the pharmacy did not, the medication is unrelated or unreasonable/unnecessary, and some have found that the medications are for patients who were not on service for the date listed. These would all be reasons to file a dispute.
UPDATE: NAHC/HAA encourages hospices to verify that the patient was on service, received the medication as stated in the refund request attachment, and the medication was reasonable and necessary and related to the principal diagnosis and related conditions before paying for the medication. Please remember that the hospice has 30 days from the date of receipt of the letter to dispute the debt.
5. PRS has made it clear that they are willing to work with providers on payment plans. It sounds as if they are willing to work with hospices on the issues identified and resolution.
Providers may find the following Q&A from the Part D Q&A document on the Hospice Center website helpful:
Q.6: Are all the drugs in the four categories identified in the 2014 Call Letter considered related and, therefore, covered under the hospice benefit? Are all maintenance drugs considered unrelated and, therefore, covered under Part D?
A.6: Any drug whether it is a maintenance drug or in the four categories of [sic] identified in the 2014 Call Letter (including analgesics, antiemetics, laxatives, or antianxiety drugs) may be unrelated to the terminal illness and/or related conditions and, therefore, coverable under Part D. As a result, coverage determinations must be made on a case-by-case basis for each drug.
The Q&A is available on the hospice center website here.
NAHC and HAA will continue to work to obtain more information and advocate on behalf of hospices, and will keep all NAHC and HAA members keep apprized of the situation as new developments unfold.
