Payment for self-administered medications provided to Medicare beneficiaries who are receiving outpatient part B services, including observation services, are statutorily prohibited from payment by Medicare part B.
Hospitals are required to bill patients for self-administered medications at the hospital chargemaster rate to avoid sanctions. The Federal anti-kickback statute, the civil monetary penalty and exclusion laws related to kickbacks, and the Federal civil monetary penalty law prohibit inducements to beneficiaries.
These self-administered medication costs increase the patient's out-of-pocket expenses for an outpatient stay by hundreds of dollars and create patient dissatisfaction.
Patients have the option to submit their bill for self-administered medications to their part D plan and request reimbursement.
Medicare part D plans often reject these requests, noting that the patient did not use an in-network pharmacy for their medications or only reimburse for the amount the plan would pay an in-network pharmacy.
On October 29, 2015, the Office of the Inspector General of the Department of Health and Human Services released the OIG Policy Statement Regarding Hospitals That Discount or Waive Amounts Owed by Medicare Beneficiaries for Self-Administered Drugs Dispensed in Outpatient Settings
This policy statement allows hospitals to discount or waive amounts that Medicare beneficiaries owe for non-covered self-administered medications the beneficiaries receive in outpatient settings and not be subject to sanctions.
The OIG set four criteria for use
-This applies only to discounts on, or waivers of, amounts Medicare beneficiaries owe for self-administered medications that the beneficiaries receive for ingestion or administration in outpatient settings
-Hospitals must uniformly apply their policies regarding discounts or waivers on self-administered medications (e.g., without regard to a beneficiary's diagnosis or type of treatment)
-Hospitals must not market or advertise the discounts or waivers
-Hospitals must not claim the discounted or waived amounts as bad debt or otherwise shift the burden of these costs to the Medicare or Medicaid programs, other payers, or individuals.
All hospitals should evaluate this new OIG policy statement for applicability to their Medicare patients.
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