Legal Guidelines for Waiver or Reduction of Medicare and Commercial Co-Payments

Legal Guidelines for Waiver or Reduction of Medicare and Commercial Co-Payments

Pharmacies have an obligation to take reasonable steps to collect co-payments from Medicare beneficiaries. From the viewpoint of the OIG, it is important for the beneficiary to pay something. This causes the beneficiary to have “equity” in the process thereby making the beneficiary a wiser consumer of health care products and services. When a pharmacy routinely waives co-payments for Medicare beneficiaries … and particularly when the pharmacy advertises that it waives co-payments, then the OIG considers this to be a kickback, inducement, and a false claim. According to the OIG, the pharmacy can only waive a co-payment when the pharmacy has made a patient-specific decision to waive…..and that decision is based on the financial condition of the patient. Contracts with commercial insurers and state statutes impose substantially the same requirements on pharmacies that bill commercial insurers. In fact, PBMs are kicking pharmacies out of network when the PBMs conclude that the pharmacies are routinely waiving co-payments. This program will discuss the requirements imposed upon pharmacies to attempt to collect co-payments from Medicare beneficiaries and commercial patients, and the steps that the pharmacy should take before waiving a co-payment. 

 

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