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Dec Legislative Update: HB 373: Tamper Resistant Drugs, Medicaid & Medicare Updates

New State Legislation

HB 373:  Tamper Resistant Drugs

This bill would prohibit a pharmacist from substituting another drug for a tamper resistant opioid analgesic drug, unless the substituted drug is also tamper resistant or consent is obtained from the prescriber.  It would require the Board of Pharmacy to create a list of opioid drugs that have tamper resistant properties, and prohibit a pharmacist from substituting another drug that doesn’t have the same tamper resistant properties, unless they have written and signed consent of the prescriber.

Tamper resistant properties include formulations that make it more difficult to crush or manipulate the product.

OPA will fight this transparent attempt by the brand name manufacturers to move their product at the expense of the patient.

Medicaid Managed Care

The switch over to Medicaid managed care did not go as smoothly as Medicaid had hoped.  On October 1, the required PBM administrative changes necessary for the switch over were not fully implemented in the system. So over 68,000 claims that were billed to ACS were adjudicated to a paid status instead of denying with a message indicating the proper MCP to bill.  Pharmacies are now being asked to reverse and rebill all claims that were incorrectly billed by Medicaid on October 1 to 3, 2011.  OPA has communicated with the Lt. Governor, the legislature, ODJFS and ACS (fee-for-service claims processor) that this problem was not caused by pharmacy, and pharmacy should not be responsible for fixing it.  The proper way to handle this is for ODJFS and ACS to work with the managed care plans to recover their claims. 

OPA will continue to work diligently on this issue and to make sure that it does not happen in the future.

Medicare News

More Medicare Revalidation Information.  The Centers for Medicare & Medicaid Services (CMS) has reevaluated the revalidation requirement in the Affordable Care Act, and believe it affords the flexibility to extend the revalidation period for another two years.  This will allow for a smoother process for providers and contractors.  Revalidation notices will now be sent through March of 2015.  IMPORTANT:  This does not affect those providers who have already received a revalidation notice.  If you have received a revalidation notice from your contractor, respond to the request by completing the application either through Internet-based PECOS or the appropriate 855 application form.

The first set of revalidation notices went to providers who are billing, but are not currently in the Provider Enrollment, Chain and Ownership System (PECOS).  We ask all providers who receive a request for revalidation to respond to that request.

For providers NOT in PECOS, the revalidation letter will be sent to the special payments or primary practice address.  For providers in PECOS, the revalidation letter will be sent to the special payments and correspondence addresses simultaneously; if these are the same, it will also be mailed to the primary practice address.  If you believe you are not in PECOS and have not yet received a revalidation letter, contact your Medicare contractor.  Contact information may be found at

CMS has posted a listing of providers who have been sent a request to revalidate their Medicare enrollment information. The listing contains the name and national provider identifier (NPI) of each provider sent a letter, as well as the date the letter was sent. To see the listing, click on “Revalidation Phase 1 Listing” in the Downloads section of the Medicare Provider Supplier Enrollment Revalidation page. NOTE:  You must widen each column in the spreadsheet to view the contents. CMS will be updating this list monthly.

If you are listed and have not received the request, please contact your Medicare contractor. Their toll-free number can be found at Medicare Fee-For-Service Contact Information.

For more information on revalidation of Medicare provider enrollment, see MLN article 1126 Further Details on the Revalidation of Provider Enrollment Information.

Changes to Medicare Overpayment Notification Process.  CMS has made changes to the Medicare Overpayment Notification Process. If an outstanding balance has not been resolved, providers previously received three notification letters regarding Medicare Overpayments, an Initial Demand Letter (1st Letter), a Follow-up Letter (2nd Letter), and an Intent to Refer Letter (3rd Letter).  CMS would send the second demand letter to providers 30 days after the initial notification of an overpayment.  Recent review has determined that this is not efficient since the majority of providers respond to the initial demand letter and pay the debt. 

Currently recoupment action happens 41 days after the initial letter.  The remittance advice which describes this action serves as another notice to providers of the overpayment.  Therefore, effective Tuesday, November 1, 2011, the second demand letters are no longer being sent to providers.  Provider appeal rights will remain unchanged. If an overpayment is not paid within 90 days of the initial letter, providers will continue to receive a letter explaining CMS’ intention to refer the debt for collection.

If you have any questions or comments about the issues mentioned in this article, please contact Kelly Vyzral, Director of Government Affairs, at 614.389.3236 or

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