New Rule Will Change Part B Reimbursement Procedure

Besides the new Medicare prescription drug benefit, the Medicare Modernization Act (MMA) has also created a new way for physicians to obtain drugs that are covered under Medicare Part B. The Competitive Acquisition Program, or CAP, was set to begin on January 1, 2006, but CMS is now saying that this voluntary program, which should affect only physicians' administrative practices rather than patient care, will not start delivering drugs until July 2006.

The intent of CAP is to alleviate the burden on physicians of tying up their capital in expensive drug inventories for which they cannot be reimbursed until they file claims with Medicare.

Currently, Part B reimburses physicians for drugs that are not self-administered by the patient. For psychiatrists, those drugs are most likely to be the long-acting injectable forms of antipsychotics. To receive reimbursement for the drugs and the cost of administering them, physicians must purchase the drugs and then file claims with Medicare after the drugs have been administered.

Under CAP, physicians will no longer have to purchase drugs. They will be able to order drugs as needed from approved CAP vendors, and Medicare will reimburse the vendors after physicians submit a claim showing a drug has been administered.

Even though the program is still set to begin officially in January, and doctors must sign CAP election agreements by November 15 to participate, the regulations governing how CAP will work have yet to be finalized. APA submitted extensive comments to the proposed rule in April, and staff are now reviewing the hundreds of pages of documentation of the interim CAP rule that was announced in July to determine what changes were made in response to APA's comments and whether new comments need to be submitted before the rule is finalized.

Although CAP was designed to benefit physicians, whether it will work well for psychiatrists will not be clear until all the details have been worked out. One of several issues that concern those who have reviewed the program is that CAP vendors may refuse to supply drugs for patients who are more than 45 days late in paying deductibles or copays for drugs administered under CAP.

OHSF will provide educational materials on CAP as soon as the rule is finalized. Look for postings on the APA Web site at<www.psych.org>. If you have questions, contact the Help Line at [email protected] or (800) 343-4671. ▪