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Medicare Advantage & Clinical Trials

Medicare Advantage & Clinical Trials. Melanie Hawkins, BSN, RN, CCRC Director, Clinical Research Billing Compliance. Changes Effective January 1, 2011.

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Medicare Advantage & Clinical Trials

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  1. Medicare Advantage & Clinical Trials Melanie Hawkins, BSN, RN, CCRC Director, Clinical Research Billing Compliance

  2. Changes Effective January 1, 2011 • Medicare Advantage Plan will be required to “reimburse” patient for additional out-of-pocket expense associated with billing Medicare – eliminates disincentive to enroll in study • OHSU will bill Medicare Advantage Plan on patient’s behalf after Medicare has paid • Patient responsible for Medicare Advantage Plan co-pay • OHSU will bill patient for co-pay • No difference for in-network vs. out-of-network #

  3. What Do We Tell New Research Subjects? • Medicare Advantage Plan Information Sheet (patient handout) • http://www.ohsu.edu/xd/research/about/integrity/irb/clinical-research-billing.cfm • No signature required – No IRB approval necessary – No scanning into Epic • Patient will be billed for Medicare Advantage co-pay even if not notified at time of study enrollment • Same out-of-pocket cost per service #

  4. What About Those Already Enrolled? • Patients who have been on trials and were grandfathered in due to lack of notification • No change - no out-of-pocket • Notification of billing change (form) is recommended to avoid confusion • Patients who were notified about Medicare billing at time of study enrollment and who are currently paying Medicare coinsurance • Less out-of-pocket • Notification of billing change recommended #

  5. Will This Change Go Smoothly?? • PBS/UMG has made already made change in registration and billing process • Some Medicare Advantage Plans are unaware of new requirement so we will be “educating” them • Some Medicare Advantage Plans will push back • Medicare has made it very clear that Medicare Advantage Plans must pay and that there is no distinction between in-network and out-of-network providers in this circumstance. • Plans may require that patient pay and be reimbursed – not allowed per Medicare #

  6. Patient Information Sheet #

  7. Other Research Billing Tidbits… • Updated Research Rates Forms • Old form has been revised and new form is available – use of either is acceptable • PBS only needs final Clinical Research Billing Schedule – do not send lay summary or Medicare checklist • Research Industrial Account Request Form still required to create research account • Forms can (soon) be found at http://ozone.ohsu.edu/research/rates/index.shtml • Device trial enrollment notification • Notify CRBO when a patient signs consent for a device trial #

  8. Questions? Call the CRBO with ANY questions about billing for clinical services on a study. • Clinical Research Billing website http://www.ohsu.edu/xd/research/about/integrity/irb/clinical-research-billing.cfm • Email CRBO@ohsu.edu • Contacts: • Kristin Couture, Clinical Research Coverage Analyst, x4-4790 • Dena Clawson, Clinical Research Billing Specialist, x4-3515 • Melanie Hawkins, Director, Clinical Research Billing Compliance, x4-8586 #

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