Rejections of drug claims for nursing home residents under medicare Part D

Health Affairs

Volumn 27, Issue 2, 2008, Pages 560-567

  Huskamp, Haiden A ^a   Stevenson, David G ^a   Keating, Nancy L ^a,b   Newhouse, Joseph P ^c  

^a HARVARD MEDICAL SCHOOL   (United States)

^b Women's Hospital

^c HARVARD UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AMLODIPINE BESYLATE; ATORVASTATIN; DONEPEZIL; ESCITALOPRAM; FENTANYL; FUROSEMIDE; HYDROCODONE BITARTRATE PLUS PARACETAMOL; LANSOPRAZOLE; LEVOFLOXACIN; LEVOTHYROXINE SODIUM; LISINOPRIL; MEMANTINE; OMEPRAZOLE; POTASSIUM CHLORIDE; QUETIAPINE; RANITIDINE; RECOMBINANT ERYTHROPOIETIN; RISPERIDONE; WARFARIN;

ARTICLE; CONTROLLED STUDY; HEALTH CARE; HEALTH CARE ACCESS; HUMAN; LONG TERM CARE; MEDICARE; NURSING HOME PATIENT; PHARMACY; PRESCRIPTION;

HUMANS; INSURANCE CLAIM REVIEW; INSURANCE, HEALTH, REIMBURSEMENT; MEDICARE PART D; NURSING HOMES; UNITED STATES;

EID: 41749107935     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.27.2.560     Document Type: Article

References (19)

1. Henry J. Kaiser Family Foundation, "Distribution of Certified Nursing Facility Residents by Primary Payer Source, 2005," http://www.statehealthfacts.org/comparebar.jsp?ind=410&cat=8 (accessed 3 November 2007).
2. D.G. Stevenson, H.A. Huskamp, and J.P. Newhouse, "Medicare Part D, Nursing Homes, and Long-Term Care Pharmacies," Report to the Medicare Payment Advisory Commission (Washington: MedPAC, March 2007), 6.
3. Ibid, 15-17.
4. Ibid, 17-21.
5. D.G. Stevenson et al., "Medicare Part D and Nursing Home Residents," Journal of the American Geriatrics Society 55, no. 7 (2007): 1115-1125.
6. See, for example, D. Mendelson et al., "Prescription Drugs in Nursing Homes: Managing Costs in a Complex Environment" (Washington: George Washington University, 12 November 2002).
7. In some cases, consultant pharmacists are not employed by the LTCP. For example, New Jersey law does not allow consultant pharmacists to be employed by an LTCP because of concerns about conflict of interest.
8. See Long-Term Care Pharmacy Alliance, "Members," 2007, http://www.ltcpa.org/mission/members/default.asp (accessed 14 January 2008).
9. For postacute nursing home stays funded under Part A, Medicare drug payments are bundled into a prospective per diem, and the home pays the LTCP for medications directly. This arrangement did not change with Part D's implementation.
10. Stevenson et al., "Medicare Part D," 14-15, 22, 26-28.
11. The total number of claims rejected in 2006 was unavailable because of data management issues of the LTCP.
12. The 4 percent rejection rate estimate is across all claims,while the rejection ratio data reflect claims in rejected status as of December 2006 only.
13. Stevenson et al., "Medicare Part D," 21.
14. Ibid., 15.
15. J. Robst, J.M. Levy, and M.J. Ingber, "Diagnosis-Based Risk Adjustment for Medicare Prescription Drug Plan Payments," Health Care Financing Review 28, no. 4 (2007): 15-30.
16. The Washington Legal Foundation has filed a lawsuit to stop enforcement of these regulations.
17. Stevenson et al., "Medicare Part D," 9-11.
18. J. Hoadley et al., "The Role of Beneficiary-Centered Assignment for Medicare Part D," Report to MedPAC (Washington: MedPAC, June 2007).
19. MedPAC, Report to the Congress: Promoting Greater Efficiency in Medicare, June 2007, pp. 175-178, http://www.medpac.gov/documents/ Jun07_EntireReport.pdf (accessed 29 November 2007).