Medicare News
| For Immediate Release: | Contact: |
| Friday, June 04, 2004 | CMS Office of Public Affairs 202-690-6145 |
For questions about Medicare please call 1-800-MEDICARE or visit www.medicare.gov. |
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MEDICARE ADDS TO LIST OF OUTPATIENT SERVICES ELIGIBLE FOR SPECIAL PAYMENT
The Centers for Medicare & Medicaid Services (CMS) has authorized hospitals to receive special payments – called pass-through payments ‑ under the Outpatient Prospective Payment System (OPPS) for five additional drugs, four of which are cancer therapies. In addition, CMS has identified an additional service for payment as a new technology in the outpatient setting. Both pass-through and new technology payments are temporary until there is sufficient cost data from outpatient services to develop an appropriate price within the OPPS.
“These new payments for new cancer treatments will help beneficiaries get prompt access to new drugs, by giving hospitals the incentive to incorporate these advances in their outpatient care promptly,” said CMS Administrator Mark B. McClellan, Ph.D., M.D.
The drugs approved for pass-through payment beginning July 1, 2004, include four injectable cancer drugs: Pemetrexed, Bevacizumab, Cetuximab, and Abarelix. In addition, CMS has granted pass-through status to Omalizumab, an injection for allergy-related asthma. Pemetrexed, Bevacizumab, and Cetuximab were just approved by the Food and Drug Administration in February 2004. Under a provision enacted in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), hospitals can submit adjustment bills to receive payment at 95 percent of average wholesale price (AWP) if they furnished these five drugs to beneficiaries prior to their approval as pass-through drugs. CMS is also making a correction to the amount it pays hospitals for the drug Fulvestrant.
In addition, CMS has also approved a treatment for fecal incontinence for payment under the OPPS as a new technology.
Payment for these new services is being implemented as part of the regular quarterly update of the OPPS scheduled for July 1. Under this system, hospitals are paid for most outpatient services based on groupings, called ambulatory payment classifications, or APCs, that are clinically similar and require similar resources. The system was required by the Balanced Budget Act of 1997, and was implemented in August of 2000. Since then, Congress has made a series of significant changes to the system that are intended to remove any financial barrier to hospitals using new drugs and technologies in treating Medicare beneficiaries.
This update also clarifies billing and coding instructions that hospitals are to follow when submitting claims to Medicare for payment of drug eluting stents.
The complete update documents can be found at: www.cms.hhs.gov/manuals.
