Chief Operating Officer
Sceptre Management Solutions, Inc.
Patients and providers using Sensipar® (cinacalcet) and Parsabiv™ (etelcalcetide) are experiencing significantly increased financial liability due to inconsistent coverage of the drugs by payers and the dramatic increase in the coinsurance amount assigned by Medicare Part B. The biggest causes of potential lost reimbursement for providers are Medicare patients without secondary coverage, Medicare patients with secondary coverage that pays little or none of the assigned coinsurance, and commercial and government payers that are inconsistent with their coverage of Sensipar and Parsabiv.
Medicare Patients without Secondary Coverage
Renal providers are very aware of how difficult it is to obtain payment from Medicare patients who have no Medigap or other secondary coverage. Because the Medicare Allowed Amount is extremely close to what it costs renal providers to provide services, every effort is made to help the patient find and obtain coverage for the 20% of the allowed amount not paid by Medicare. However, in some cases, patients cannot find an affordable Medigap policy nor do they qualify for financial assistance. This leaves providers stuck with trying to collect large amounts from patients whose monthly coinsurances can exceed the cost of the secondary insurance premiums they cannot afford.
To illustrate the magnitude of the increased coinsurance amounts, we will use Sensipar dosing as an example. The minimum recommended daily dose is 30 mg and patients can go as high as 180 mg. The current Medicare allowed amount for this drug is 90.9 cents per mg. Thus, a patient on 60 mg per day receives 1800 mg during a 30-day month. Medicare’s allowed amount for this amount is currently $1636.20, but they only pay 80% of that amount or $1308.96. The difference, $327.24, is assigned as the patient’s responsibility. This amount is on top of whatever the patient’s normal monthly liability is for treatments paid under the Bundle, which normally runs from $400 to $1,000 per month. Thus, a patient who was assigned a $400 coinsurance in November 2017 would have a $727.24 liability in April 2018, an increase of 82%. If the same patient had a daily dose of 120 mg, the patient’s liability is $654.48 just for the Sensipar, which makes the total assigned coinsurance $1054.48, an increase of 164%.
Patients who cannot afford a secondary insurance policy often pay little or nothing toward their assigned Medicare coinsurance liability. Continuing with the patient example from the preceding paragraph, prior to January 2018 the provider would have lost out on $400 of reimbursement for a month. Now, the amount becomes a minimum of $563.87 for a patient taking the minimum dose of Sensipar to $1381.72 for a patient taking the maximum dose of 180 mg daily. Of course, if the patient’s coinsurance was $800 per month prior to January, the provider’s potential lost reimbursement per month equals somewhere between $963.87 and $1781.72.
Adding Insult to Injury
Obviously, it is extremely important for providers to do everything they can to help Sensipar and Parsabiv patients obtain insurance coverage for the coinsurance assigned by Medicare. However, not all secondary policies are created equal.
In a number of states, Medicaid pays little to nothing towards a renal patient’s assigned Medicare coinsurance. Since Medicaid is a “payer of last resort,” providers cannot bill the patient for any unpaid portion of the coinsurance unless the patient has a monthly deductible, commonly known as a “spend-down.” The amounts assigned to patients with spend-downs may cover some or all of the coinsurance, but only if the patient pays the provider.
Some commercial and government payers do not yet cover Parsabiv, leaving patients with the full liability for payment of the drug. Some policies will cover Sensipar, but only as a pharmacy benefit, so any amount provided to these patients by an outpatient dialysis facility will likely not be covered. In this situation, make sure affected patients continue to receive Sensipar through their pharmacy.
Another problem that can cause lost reimbursement occurs when the provider has signed a “global” or “all-inclusive” contract with a payer. These contracts may result in a payer not reimbursing anything additional for Parsabiv and Sensipar on the grounds that the contract already covers all services, supplies, or medication provided to patients. Similarly, contracts that list specific items covered by the payer likely did not include Sensipar and Parsabiv at the time they were signed, so payers can state they will not cover the drugs because they are not specified in the contract.
So, what can be done to provide patients with Parsabiv and Sensipar without dramatically increasing the financial liability of both patients and providers? The first step for providers is to reach out to payers not reimbursing for these drugs or reimbursing them below cost. For commercial payers, have your global or procedure-specific contracts amended to include adequate coverage for the drugs. Normally, this can be accomplished through the payer’s contracting department, but if necessary, contact the payer’s medical director and insist on having these drugs appropriately covered for your patients. For government payers not providing adequate coverage for the drugs either as a primary or secondary payer, contact the payers’ medical directors, administrators, and, if necessary, your state or federal congressional leaders. Contacting the media about the failure of commercial or government payers to cover the drugs is also an option.
Additional options are provided by Amgen, the maker of both Parsabiv and Sensipar. Amgen offers coverage assistance for qualifying patients and can assist with verifying coverage for these drugs with various payers.
Rick Collins is the director of business development for Sceptre Management Solutions, Inc., a company that specializes in billing for dialysis, nephrology, and interventional nephrology programs. Please direct your comments or questions to him at firstname.lastname@example.org or 801.775.8010.