Take Home Meds: To Bill or Not to Bill 7/12/21

The past few years have seen an increase in “Take-Home Meds” Programs. There are specific billing rules that apply to Medicare patients with Part A, B and/or D coverage who opt to receive “Take-Home Meds”.

Inpatients

If only a limited supply is needed to cover the time from discharge until an inpatient can get a prescription filled in a network pharmacy, hospitals are permitted to dispense a limited supply and include it in the Part A (inpatient) claim (and not bill Medicare Part D or the patient). 

Chapter 1, Section 30.5 Drugs For Use Outside the Hospital in the Medicare Benefit Policy Manual contains the following:

“Drugs and biologicals furnished by a hospital to an inpatient for use outside the hospital are, in general, not covered as inpatient hospital services. However, if the drug or biological is deemed medically necessary to permit or facilitate the patient’s departure from the hospital, and a limited supply is required until the patient can obtain a continuing supply, the limited supply of the drug or biological is covered as an inpatient hospital service.” 

A patient does not need to have Part B or Part D coverage to receive this limited supply when being discharged from an inpatient status. Providers are encouraged to document the drugs dispensed to the patient noting that they were necessary to “permit or facilitate the patient’s departure.”

Outpatients

Take-home medications for outpatients (including observation and emergency department patients) completing their stay are subject to the October 2015 OIG policy. Although hospitals may waive or discount self-administered drugs that are provided for ingestion or administration while the patient is an outpatient of the hospital, the same discounting does not apply to medications which are provided as a “take-home” medication. (Note: A beneficiary is not considered an outpatient if the only service received from the hospital is the dispensing of a drug for subsequent self-administration).

There are no provisions for protection from Federal anti-kickback, fraud and/or abuse statutes for a patient to receive a “limited supply” after an outpatient encounter without billing to the Part D insurance and/or beneficiary.

SHOUT-OUTS!

1. When developing “Take-Home Meds” programs, hospital pharmacies should identify the status (inpatient vs. outpatient) of Medicare patients to determine options available to provide the patient with a “limited supply” or a full prescription of medication upon discharge.

2. Pharmacy and Revenue Integrity should ensure that a “limited supply” of medications to facilitate a discharge is added to the inpatient Part A claim and not billed to Part D insurance or the beneficiary and that an appropriate notation is included in the medical record.

3. Pharmacy and Revenue Integrity should ensure that for Medicare outpatients, either a limited supply of “take-home” medications or a full prescription must be billed to the Part D plan and/or beneficiary. Medicare outpatients may include observation patients and emergency department patients.