With Medicaid, It Is Never Too Late

Pills spilling out of a prescription bottle on 100 dollar paper currencyThe Center for Medicare and Medicaid Services (CMS) has proven once again that it is never too late to file a claim for reimbursement. They have always allowed extremely late adjustments to invoices going back to the start of the Medicaid program in 1991.

With their Release 91, the CMS has now opened the door for requesting reimbursement for drugs paid for well after the time they could legally be dispensed. More specifically, for drugs dispensed before the expiration date, a rebate must be paid regardless of when the State paid for the drug or invoices the manufacturer.

I’m sure that some states are now combing through their prior disputes going back to 1991 to determine what utilization can now be submitted or resubmitted for reimbursement.

What Does This Mean For Manufacturers?

This raises several questions about the potential liability and how to process the claims. For example,

1. In the claims going back to 1991 where disputes were raised about invoices after expiration, is there good documentation about which disputes are still valid due to the dispense date (do you have the script information to back up this assertion) vs which are now eligible for rebates?

2. What is the total new liability that you might have for the now eligible rebates?

3. Can you get the State to at least invoice this late paid utilization in a quarter for which you have already calculated the correct rebate amount to simplify your process? For at least the last question, the answer seems to be yes as there are indications that states are willing to invoice that utilization in a manageable quarter, reducing at least one operational burden.

Of course the other question about Medicaid and “lateness” is whether we will ever see the long anticipated, and late by any criteria, AMP rule.

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