The CAP is back on for physicians... again!

June 1, 2006

You do not have to write a check for the drug, nor do you have to collect for it, but you are still involved in the process.

Further, CMS indicated that prior to the sign-up date, which would begin on April 3, 2006, a list of CAP vendors would be published.

After reviewing the contract, four dropped out, leaving one vendor.

At the same time, CMS indicated that the sign-up would begin later in the spring.

What went wrong

First and foremost, the law specifically stated that each physician in each area would have a choice of at least two vendors. This is not the case. Also, as of the finalization of this article, we have not seen a contract that will be signed between the physician and the CAP vendor.

CMS and Congress have stated that their intent is to allow physicians to have their drugs furnished for their patients by a vendor without having to worry about purchasing or collecting payment for the drugs administered. However, they have created a program in which you, in essence, have hired a surrogate biller. It is true that you do not have to write a check for the drug, nor do you have to collect for it, but you are still involved in the process. You're just not paid for your assistance in collecting for the drug. You will continue to bill for and be paid for the injection fee and any E&M services provided.

How the system works

The way the system works is as follows:

BioScrip will outline specific policies in the contract signed by CAP participants. Under current policy, the vendor is required to:

BioScrip is permitted to:

Read contracts carefully

As the saying goes, "The devil is in the details."

By the time you read this article, BioScrip model contracts will be available. Obviously, the detail of the contract will provide more specific answers as to how the CAP vendor program will work. Remember that CAP participation is a 6-month commitment with very few outs for the remainder of this year. All of your Medicare Part B patients will be affected by your decision to participate or not.

Before participating, read the contract carefully and understand the details. Certainly, the decision is a personal one, with many factors that have to be taken into consideration.

If you decide not to participate in the CAP, you can continue to provide drugs in your office under Medicare Part B, as you have for years. Obviously, the profit margins for provision of these drugs in your office have changed in the past 2 years.

We realize there has been some discussion about the possibility of losing money when you're buying and selling pharmaceuticals under the average sales price plus 6% reimbursement due to the expenses related to provision of the drug. While the prospect of monetary losses is possible, our calculations currently point to increased administrative expenses without increased reimbursement under the CAP, and, more important, a further loss in direct control of patient therapy. Therefore, we still think it is in the best interest of your patients and your practice not to participate in the CAP.

Instead, we would like to recommend that you establish a relationship with a pharmaceutical company that will treat you fairly in contracting. With fair contracting, properly managed inventory, and accurate billing, you will be able to buy and provide drugs to your patients without losing money.

In addition, many of the pharmaceutical companies are taking steps to make it easier for you to track your inventory and your reimbursement so that you can be assured that you are making good business decisions in your contracting.

As we travel around the country and ask the question in seminar after seminar, we find very few urologists intend to sign up to participate in the CAP. We are as interested as you in seeing how it works and if it will be of value. We wish you luck with the decision you make.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook.Mark Painter is CEO of PRS Urology SC in Denver.

Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.