Medicare Question

[busy-bee]

When an order is placed through the company pharmacy........does medicare pay the pharmacy directly? And as well as private pay individual with their own insurance company that do not qualify for medicare...is the pharmacy paid directly from the insurance company?

Also, if a patient is covered via medicare............and has a colostomy.........and the facilities colostomy supplies is not what the patient wants to use, does medicare pay for the colostomy supplies?

[woody62, RN]

Guess I was lucky all a round. I was a surfer girl back in the early 60s. Use to surf off La Jolla(?) Coves. And I never got my brains scrambled, although I did wipe out when I first started surfing.

Woody:balloons:

[Nascar nurse, ASN, RN]

Now say hypothetically, the pharmacy does not get payment for say....4 months. What would be expected? Or do they pay quaterly, monthly, or what? There are rumors going around our facilitly and I am trying to sort the truth from the rumors. Please reply to the question at hand.

Sorry, no idea with this. That would be between the pharmacy and the facility.

[Nascar nurse, ASN, RN]

I was in a LTC for wound management and rehab. My drug orders were written by a physician who was responsible for me during my stay. The LTC center got them from a local pharmacy. The pharmacy billed Medicare. I do not know how long they waited for payment but I was discharge home before the pharmacy received its first payment.

Woody:balloons:

Jeez, I almost hate to get involved w/ this here ... but are you SURE or did you assume that medicare paid the pharmacy, instead of the LTC.

My understanding is that once a facility accepts medicare payment for medicare A residents they have an absolute obligation to pay for all services needed (ie: pharmacy, labs, x-rays, therapies, etc). To do otherwise will constitute medicare fraud and that is baaaaaad!(ya don't want to go there).

Trust me, I sit in a long boring meeting every month and we go thru each and every medicare A residents medicare bill as a group. We triple check all this stuff and it includes pharmacy charges.

[Daytonite, BSN, RN]

busy-bee...i see you are in ltc. medicare is a medical insurance plan than is administrated by the u.s. federal government, specifically by the centers for medicare and medicaid services under the u.s. department of health and human services. people who have medicare medical insurance are usually retired workers, but can also be disabled or qualify for this coverage by some other allowed circumstance. medicare has several "parts" and each "part" covers specific types of medical services. part a covers acute hospital and nursing homes. part b covers doctors services and other types of outpatient things.

the services provided to ltc patients who qualify for medicare are paid under the mds prospective payment system. it is similar to the drg system used by the acute hospitals, but not quite the same. what your mds nurse does has a big determination on how much money your facility ultimately receives for each medicare patient it admits and treats. the ltc facility is paid a lump sum payment for the person's medicare bill at the facility. the pharmacy bills the facility for drugs sent to the patient and it is the responsibility of the facility to pay this bill out of the lump sum money it receives from medicare for the care of the patient. the facility is not permitted to deny the patient services they are entitled to under the medicare rules because of cost (the facility trying to pinch pennies) or medicare will slap the facility with fines and arrange some federal jail time for the people continually disobeying these rules. your state medicare intermediary or carrier may place some restrictions on what benefits it may pay for, but it is the responsibility of the facility billers and others who have the responsibility of managing the medicare patients to check this information out on the cms website and give the patient correct information or, once again, medicare will slap them with fines and jail time. the medicare people are very adamant about providers not screwing with patient's benefits that they are entitled to.

your state medicare intermediary who pays these bills may have placed some specific restrictions on certain very expensive drugs, but that is something that your mds coordinator, pharmacy service, administrator and the person responsible for the facility billing should be aware of. in most facilities i worked, the administrators wanted any left-over medications of our discharged medicare patients sent back to the pharmacy for credit--pinching every penny, you know.

when dme (durable medical equipment, a medicare term) purchases need to be arranged, these expenses are covered by part b of medicare, if the patient has enrolled in part b. the patient pays 20% of part b expenses and medicare pays the other 80%. part b expenses are things such as chemotherapy, wheelchairs, hospital beds, nebulizers, some ambulance services, and many others. each state medicare carrier has the ability to restrict some things that it will cover under part b, but not all.

ostomy (colostomy) supplies are covered under part b of medicare. each state may have some restrictions on what the medicare carrier is going to pay for that state. as an example, here is what the medicare carrier in the state of maine will pay for ostomy supplies: http://www.medicare.gov/coverage/search/results.asp?state=me%7cmaine&coverage=44%7costomy+supplies&submitstate=view+results+%3e

if you want to find out more about medicare benefits you can go to the cms (centers for medicare and medicaid services, the official title of medicare) website to learn about it. they also publish a yearly patient manual, medicare and you that specifically explains what is absolutely covered under part a and part b of medicare. you can download and read it here: http://www.medicare.gov/library/pdfnavigation/pdfinterim.asp?language=english&type=pub&pubid=10050

this webpage will give you an overview of medicare

• http://www.cms.hhs.gov/medicaregeninfo/

this is the computer friendly medicare site for citizens

• http://www.medicare.gov/

[Daytonite, BSN, RN]

so the facility pays the contracted pharmacy by the funds they receive from medicare, correct? yes now say hypothetically, the pharmacy does not get payment for say....4 months. what would be expected? or do they pay quaterly, monthly, or what? there are rumors going around our facilitly and i am trying to sort the truth from the rumors. please reply to the question at hand.

the last part of your question is a little hard to answer. what happens if you or i don't pay a bill that we owe? nasty letters start showing up in our mailboxes. credit with that store gets cut off. just try to buy something else from that store and say "put it on my bill" and see how far you get out the door with it. ha! ha! business works the same way. it's impossible to know what kind of payment arrangements your facility has with the pharmacy they use and whether or not they pay on a monthly or quarterly basis. you would need to go to someone in the office and ask them. you'll probably get a good long stare from them if you do this, however. you might even be told that it's none of your business (just want to prepare you).

rumors are hard to separate from the truth, aren't they? gossip can be a real killer of morale. as nurses we don't need to hear this kind of upsetting stuff. we are constantly told to keep our focus on nursing and not worry about all this business end of things. all i can say is, if you feel confident and brave enough, get the information (gossip) together that you have heard and who is telling it. ask to have a sit down with the administrator of your facility. be cordial and businesslike. tell him/her the rumors that are circulating and how upsetting it is. ask them if they can clarify or correct what is being said because it is affecting work. ask for reassurance that the place is not going under. ask for direction from the boss on how you should handle these snippets of gossip when you hear them. you can judge a lot from the way you are treated in a meeting like this. if there is a problem you need to do your part in helping the administrator identify it so he/she can nip it in the bud. maybe the administrator has an accountant who is screwing up at their job. maybe there are billing disagreements between the pharmacy and the facility that aren't getting resolved and the pharmacy people have started a bad-mouthing campaign. maybe the checks got lost in the mail. maybe the facility is just a deadbeat payer. not all ltc owners are financial wizards at balancing their checkbooks. who knows?

best of luck to you.

[woody62, RN]

Jeez, I almost hate to get involved w/ this here ... but are you SURE or did you assume that medicare paid the pharmacy, instead of the LTC.

My understanding is that once a facility accepts medicare payment for medicare A residents they have an absolute obligation to pay for all services needed (ie: pharmacy, labs, x-rays, therapies, etc). To do otherwise will constitute medicare fraud and that is baaaaaad!(ya don't want to go there).

Trust me, I sit in a long boring meeting every month and we go thru each and every medicare A residents medicare bill as a group. We triple check all this stuff and it includes pharmacy charges.

Yeb, I am sure that the facility I was in got their drugs from an area pharmacy. I had a medication changed and when I requested it, I was told they had to send someone to the pharmacy they use, to obtain it. I also was at the nurse's station, waiting for my turn at P.Y., when I observed a person enter and leave several big bags at the station. I asked what was in them and was told there were patients medications in them. And I watched, as a nurse emptied them and put them in patients drawers, in the med cart.

Now it is possible that I had experience short and long term memory loss and imagined the entire episode. But I don't think so.

Woody:balloons:

And by the way, my roommate's daughter works at a local LTC facility, as a nurse. I recently asked her about how they obtained their drugs. She told me the same thing that I had witnessed. And she worked at a different facility. Perhaps it is something local to Charlotte County.

[TazziRN, RN]

Yeb, I am sure that the facility I was in got their drugs from an area pharmacy. I had a medication changed and when I requested it, I was told they had to send someone to the pharmacy they use, to obtain it. I also was at the nurse's station, waiting for my turn at P.Y., when I observed a person enter and leave several big bags at the station. I asked what was in them and was told there were patients medications in them. And I watched, as a nurse emptied them and put them in patients drawers, in the med cart.

Now it is possible that I had experience short and long term memory loss and imagined the entire episode. But I don't think so.

Woody:balloons:

And by the way, my roommate's daughter works at a local LTC facility, as a nurse. I recently asked her about how they obtained their drugs. She told me the same thing that I had witnessed. And she worked at a different facility. Perhaps it is something local to Charlotte County.

Once again, Woody, you are not answering the question/comment as it was written. The original question asked you was "Are you sure that Medicare paid the pharmacy and not the LTC?" Not, "Where did you get your meds from?" Of course your meds came from an area pharmacy, but did the LTC pay the pharmacy and get reimbursed from Medicare, or did Medicare pay the pharmacy directly?

What Nascar describes is how HH works. We get a flat amount for each patient based on what we deem is needed on the initial exam, and that's all we have to spend on that pt for 60 days. If we run through the allowance and the pt needs more from our agency, we have to absorb the cost.

[woody62, RN]

Once again, Woody, you are not answering the question/comment as it was written. The original question asked you was "Are you sure that Medicare paid the pharmacy and not the LTC?" Not, "Where did you get your meds from?" Of course your meds came from an area pharmacy, but did the LTC pay the pharmacy and get reimbursed from Medicare, or did Medicare pay the pharmacy directly?

What Nascar describes is how HH works. We get a flat amount for each patient based on what we deem is needed on the initial exam, and that's all we have to spend on that pt for 60 days. If we run through the allowance and the pt needs more from our agency, we have to absorb the cost.

I would love to post a copy of my bill from the LTC facility I was in. As well as copies of my Medicare Part D payouts. To answer your question, my Part D was billed by the pharmacy that provided all of my medications while I was in the LTC facility, as well as the p[provider for the IV solutions I received after being discharge back to the LTC facility. I cannot find any billing to Medicare, from the facility, for any of the drugs and IV's I received.

I am well aware of how HHC is paid. I was once told that no one, on Medicare/Medicaid could remain on long term home health care and expect Medicare/Medicaid to pay. I have a friend, living in Brooklyn, that has been on such care, living in her rent controlled apartment for more then 12 years. When Medicare switched to the lump sum payment program, her Home Health Care Agency tried it's darnest to discharge her to a nursing home. She is still on home care. And the M.S. Society continues to fight on behalf of their members.

Sorry if I sound anti-home health care. I once was not. I once worked for the Visiting Nurse of Brooklyn, a non-profit home health care provider. Since living here in Florida, I have changed my support and my mind. I've been soured by the many for-profits here.

Woody:balloons:

[Nascar nurse, ASN, RN]

Yeb, I am sure that the facility I was in got their drugs from an area pharmacy. I had a medication changed and when I requested it, I was told they had to send someone to the pharmacy they use, to obtain it. I also was at the nurse's station, waiting for my turn at P.Y., when I observed a person enter and leave several big bags at the station. I asked what was in them and was told there were patients medications in them. And I watched, as a nurse emptied them and put them in patients drawers, in the med cart.

Now it is possible that I had experience short and long term memory loss and imagined the entire episode. But I don't think so.

Woody:balloons:

And by the way, my roommate's daughter works at a local LTC facility, as a nurse. I recently asked her about how they obtained their drugs. She told me the same thing that I had witnessed. And she worked at a different facility. Perhaps it is something local to Charlotte County.

Oh but my comment didn't apply to WHERE the meds came from (they can come from ANYWHERE the facility decides to contract with.... my point was that the FACILITY ultimately paid the pharmacy, not medicare paid the pharmacy.

[Nascar nurse, ASN, RN]

I would love to post a copy of my bill from the LTC facility I was in. As well as copies of my Medicare Part D payouts. To answer your question, my Part D was billed by the pharmacy that provided all of my medications while I was in the LTC facility, as well as the p[provider for the IV solutions I received after being discharge back to the LTC facility. I cannot find any billing to Medicare, from the facility, for any of the drugs and IV's I received.

Woody:balloons:

Well this is just plain screwy, cuz this is not how it works! Maybe you got ripped off?? Medicare covers the first 20 days in LTC at 100%, the other 80 days are covered at 80% and the resident is billed a predetermined (amount determined on a regional basis I believe) amount for the other 20% - currently ours would run about $140/day I think. Thats it - that is all the bill a resident receives. There wouldn't even be a reason to send the resident any kind of bill for pharmacy services or any information as to how it got paid... it wouldn't be their worry!

Again... this is for those on medicare A only, this does not include private pay or medicaid individuals.

[woody62, RN]

Oh but my comment didn't apply to WHERE the meds came from (they can come from ANYWHERE the facility decides to contract with.... my point was that the FACILITY ultimately paid the pharmacy, not medicare paid the pharmacy.

And my answer is that my Part D provider paid the pharmacy. No where, on any of my bills, from the LTC facility, am I charged nor did the facility list a charge from the pharmacy for any of my medications, something they would have to do if they were paying the pharmacy for my drugs.

I do not know how much more clearly I can put this. The pharmacy charge my Part D provider for all the medications I received. A different supplier charged Medicare for my IV antibiotics that I received for two weeks after my readmission. While I was an inpatient, Charlotte Regional billed for my stay. As a matter of fact, they billed over $200,000 to Medicare. Unfortunately for them, they are considered a rural provider. They only received $15,000. And they could only bill me for my Medicare deductable. Kind of a bum deal but it will remain so until they get their designation changed, something all three hospitals have been trying to do for more then 12 years.

Woody:balloons:

[Nascar nurse, ASN, RN]

Kind of a bum deal but it will remain so until they get their designation changed, something all three hospitals have been trying to do for more then 12 years.

Woody:balloons:

AHHHH, maybe this is the technicality that we are missing. You refer to a "designation change" and the word "hospitals".

I am referring to an extended care, skilled nursing facility only. I am not familiar with how other "licensed" facilities bill, but I am sure there are differences.