Key Deadlines Updated for Providers Transitioning Out of CAP
On November 26, 2008, the Centers for Medicare & Medicaid Services (CMS) updated guidance on claims-submission deadlines and unused drugs for physicians transitioning out of the Medicare Part B Competitive Acquisition Program (CAP).
The guidance is as follows:
CAP Drugs Administered during 2008
- CAP drug claims must have a date of service on or before December 31, 2008;
- Physicians' corresponding CAP drug administration claims must be submitted on or before January 30, 2009; and
- CAP drugs not administered by December 31, 2008, are considered to be the property of BioScrip, the approved CAP vendor.
CAP Drugs NOT Administered by December 31, 2008
- CAP physicians must return any unused CAP drugs to BioScrip by February 28, 2009;
- Physicians who have not returned these drugs to BioScrip by then will be responsible for the costs of the unused CAP drugs; and
- CAP physicians may also contact BioScrip to discuss the option of purchasing unused CAP drugs.
Emergency Restocking of CAP Drugs for Dates of Service on or before December 31, 2008
- Physicians may request replacement drugs under the CAP's emergency restocking provisions if:
- The date of service is on or before December 31, 2008; AND
- The corresponding drug administration claim has been submitted on or before January 30, 2009;
- Physicians must request replacement drugs by January 30, 2009;
- BioScrip will not send replacement products under the CAP emergency restocking provision (J2 modifier claims) after February 28, 2009; and
- CAP physicians who have not submitted a prescription order and a request for replacement drugs under the emergency restocking provision will not be able to bill Medicare under the average sales price (ASP) system for the CAP drugs that they administered on or before December 31, 2008, from their private stock.
CMS is urging physicians who participated in the CAP during 2008 to contact BioScrip and reconcile their inventories as soon as possible.1
Background
On September 10, 2008, CMS announced that the 2009 CAP would be postponed. The postponement resulted after CMS and potential CAP vendors could not agree on contractual terms to continue the program into 2009.
In 2006, the CAP was developed as a voluntary program through which a list of Medicare Part B drugs and biologics were made available to providers when furnished in the physician office setting. The CAP provided an alternative to the traditional buy and bill process for Medicare Part B drugs. Drugs such as REMICADE® (infliximab) were on the CAP list of drugs. Under CAP, participating physicians would not assume financial risk for CAP drugs they provided to Medicare beneficiaries and would only bill for professional services, such as drug administration.
CAP Process
Physicians who participated in the CAP obtained their drugs through the designated CAP vendor (BioScrip) and would only bill Medicare (physician's local Medicare carrier) for the administration of the drug, and bill the patient for any applicable co-payment or co-insurance specific to the administration of the drug. BioScrip would bill Medicare's claims-processing carrier (Noridian Administrative Services) for the drug and bill the patient for any applicable co-payments or co-insurance specific to the drug.
In July of 2008, BioScrip announced that it would not be renewing its contract with CMS to be a CAP vendor. Several months prior to this announcement, CMS had also started to accept competitive bids for vendor contracts for the 2009-2011 CAP cycle period. Although CMS received a number of qualified bids, contractual issues with the potentially successful vendors prevented the continuation of CAP into 2009.2
1 CMS. CAP Claims Submission Deadlines and Unused CAP Drugs. Available at: www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp. Accessed December 2, 2008.
2 CMS. Competitive Acquisition for Part B Drugs and Biologicals. Available at: www.cms.hhs.gov/CompetitiveAcquisforBios/. Accessed December 2, 2008.
Coverage policies may vary by insurer or even between plans offered by the same insurer. This information is presented for informational purposes only and is not intended to provide reimbursement or legal advice. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current, the information may not be as current or comprehensive when you view it. Please consult with your counsel or reimbursement specialist for any reimbursement or billing questions.