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Proposed Medicare Reimbursement Rate Insufficient

The Centers for Medicare and Medicaid Services (CMS) recently published a proposed new reimbursement formula for clotting factor given in the hospital outpatient setting. The new formula would apply to any factor that might be given, for example, to a patient seeking treatment for a bleed in an emergency room. This particular CMS ruling is only one in a series of proposed new rulings that have been issued over past few years governing Medicare reimbursement.

The proposed formula would provide reimbursement at the rate of Average Sales Price (ASP), plus six percent, plus an additional two percent to cover administrative expenses. Unfortunately, this rate is lower than the $0.14 furnishing fee that was established for products given in inpatient and other settings, and it is inadequate considering the costs involved in properly handling clotting factor products. As a result, hospitals may be asked to absorb the difference, or, more likely, they would attempt to pass this cost on to the patient.

NHF has sent comments to CMS on the proposed rule to this affect, and has requested that they adjust the formula so that factor given in the hospital outpatient setting be reimbursed at the same rate as factor given in the inpatient and all other settings. Click here to view a copy of NHF's comments to CMS. NHF will continue to follow up on this issue, and provide the community with information as it develops.


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