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Psychiatric Practice and Managed Care
Be Alert for CAP Information
Psychiatric News
Volume 41 Number 7 page 20-20

Sometime in April, the Centers for Medicare and Medicaid Services (CMS) will be posting a list of participating Competitive Acquisition Program (CAP) vendors and the drugs they will supply on the CMS Web site at<www.cms.hhs.gov>. After the information is posted, physicians who want to participate in the program for 2006 will have 45 days to sign up. The program, originally scheduled to begin on January 1, is now set to begin July 1.

CAP was mandated by the Medicare Modernization Act of 2003, which is also responsible for the creation of the Medicare Part D prescription drug benefit. The intent of CAP is to relieve physicians of the financial burden of having to maintain expensive drug inventories for drugs they administer under Medicare Part B, Medicare's outpatient coverage. Currently, physicians cannot be reimbursed for Part B drugs until the drugs have been administered to a patient and a claim is filed with Medicare for the service. Part B covers only drugs that the patient does not self-administer. For psychiatrists, the only drugs they are likely to administer are the long-acting injectable forms of antipsychotics.

Physicians who sign up for CAP will be able to order drugs as needed from the approved CAP vendor for the drug categories they have selected, and the vendor will be reimbursed when the physician files a claim showing the drug has been administered. Physicians who elect to participate in CAP must agree to submit claims to Medicare within 14 days of the administration of a CAP drug, using delineated CAP modifier codes on the claim. Election to participate in CAP will be done on an annual basis.

In the case of emergencies, where there is no time to obtain the drug from the CAP vendor, physicians can provide the drug from their own stock and obtain a replacement from the vendor. If the CAP vendor does not stock the drug, physicians can bill Medicare as before using the average sales price method. There is some concern about how physicians will deal with the rule that CAP vendors may deny drugs for patients who are more than 45 days late paying their copays or deductibles.

More information about CAP is posted at<www.cms.hhs.gov/Transmittals/downloads/R777cp.pdf>.

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