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Old 01-03-2009, 08:49 PM   #1
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Medicare/Pain Pump

Has anyone else on this board been advised by their PM that due to Medicare not paying for the cost of pain medication, the PM has advised you either you will have to find a new PM who will refill their pain pump or have the pain pump removed? I just had my pain pump installed last year and now my PM says he is losing too much money because Medicare will not pay the cost of the pain medicine and he is losing too much money and can no longer provide service to his pain pump patients.

I talked to another PM in my area and he stopped providing refills to pain pump patients last year due to this problem. I am on fentanyl 10,000 mcg which is probably the most expensive of the pain medications but I am allergic to morphine and dilaudid and cannot change over to a cheaper pain med.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
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Old 01-04-2009, 03:19 AM   #2
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Re: Medicare/Pain Pump

Hi L5 S1, Yes they have to write off a portion of the meds just like any other HMO, PPO or negotiated contract providor would. Basicaly I would report this guy. With medicare it's all or nothing. He either excepts medicare asignment or he doesn't. It's not his right to pick and choose and actually force someone to have a working pump removed. The only med I can really imagine him loosing money on would be the fentanyls or Prialt. They make it up elsewhere and it's likely illegal what he's doing. He can loose his ability to treat all medicare patients and that will cost him big time, more than a few hundred a month on a few patients with pumps.

This is absurd and totally against the rules. Call CMS or your medicare providor if you opted to go with a private pay for fee service. I actually switched away from the basic medicare plan to have lower copays for doc vsists, but the cost of my pump visit went from 55 for a refill to 95. The other company covered things like the refill kits that medicare simply wasn't going to pay 120 bucks for a paper drape with a hole cut in it and 3 batadine swabs in a packaged plastic tray, this left me paying 20% of that which I know more than coverd the actual entire cost of the kit.

So I switched back to the plain part A and B and if a doc excepts medicare, he excepts all medicare patients, This means he can't pick and chose which ones he treats or he won't be treating any. He may not recomend pumps in the future to not blatently descriminate, but he's has already shot himself in the foot. Call medicare.
Good luck , Dave

Last edited by Shoreline; 01-04-2009 at 12:28 PM. Reason: spelling

 
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Old 01-06-2009, 10:50 PM   #3
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Re: Medicare/Pain Pump

Shoreline,

Thank you for the information. I know physicians have to treat patients who are on Medicare but can a physician decide to no longer provide a particular treatment in his office without it affecting the physician being a Medicare provider?

I also would like to verify with you if the pain medication for your pain pump is covered under Medicare Part B because it is an injectable medication which has to be conducted in a physician's office. My PM said he would provide me a prescription and I can take it the pharmacy which compounds the medication and bring it back to his office and it would be treated under Medicare Part D since I picked up the prescription. I still think that is wrong because the point of injection is still at the PM office.

I will contact Medicare and get a clarification on whether a PM can no longer provide a service to his patients without it affecting his Medicare provider status. I have heard a couple other PM doctors in my area which are doing the same thing to their patients and the nurse whohis refilling my pump now was laid off from one of the PM who stopped providing pain pump refills to his patients.

I have been making calls and emails for the past 2 weeks solid and I cannot get any information from any Medicare Supplement Insurance Companies. The Insurance Commission in my state said they could not help me until I had an actual claim and I told them I cannot have a claim because the PM will not refill my pump and I needed help on this problem. I do not know if they will help me or not. I also called Medtronics and they said they were going to investigate the problems and they have not called me back. Medicare won't advise me of the benefit amount on how much the fentanyl will cost me or the doctor because they say it changes every few days and I would have to have the pump refilled and then the claim will tell me how much it pays. Everything has to be done after the fact and I cannot get any answers.

The PM has already started reducing my dosage every couple weeks in preparation for the pain pump removal surgery. This whole thing is just insane that I paid a lot of money to have the pump surgery and now it now has to be removed.

I will let you know what I find out and I appreciate all your advice.
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
Old 01-07-2009, 12:25 PM   #4
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Re: Medicare/Pain Pump

I started wtith morphine and now have dilaudid 25 mgs per ml in my pump, It's covered by medicare part B and my usual cost for a refill visit is 55, except last year when I went with Eatna, imy portion jumped to 95 although regular doc visit copays reduced to a flat rate rather than 20%. If you have the newer pump that holds 45 ml, I'm sure it looks like a bigger loss, but whether he has to write off every 2 motnhs for my 18ml pump or every 6 months for a 45 ml pump, it probably works out the same over time.

He's BSing you as far as Part D covering your meds for the pump. Part B should cover it just like they would if he used profonol to sedate you for a nerve block. What's next, no anesthesia for precedures if you are a medicare patient because they don' like the reimbursment amont. Find another certified pump doc if you were happy with your Pump. If you contact the manufacturer they will provide a list of docs in your area, but what he is doing is wrong. I would bet it says on your EOB that your not responsable for whatever portion isn't covered.

I don't know if medicare works like HMO's but my friend was paid 1.3 mil his first year in practice of genral surgery to join an HMO and except their patients and their negoptiated fees. That's 1.3 whether he ever sees a patient or not. He has to except the HMo patients if they come knocking and he has to accept the asigned amount for each procedure. The benefit aside from the lump sum up front, is the tax write off for what they do have to write off.

My wife has Botox injectins in her neck and she went through the same thing. But no pharmacuetical providor is going to ship you a bottle of injectable high potency narcotics to take to your doc. That's just a smoke screen trying to put the responsability on you to figure it out when he already has a deal with medicare. I bet even your 90 day mail order wholsaler can't quote you a price because it simply isn't done. Trust me, He's not paying what he's asks medicare for, they pump up the cost for the write off and to try to maximize reimbursement.

I remeber one ER visit back when I had an HMO, the ER asked for 24 dollars for the demerol in one injection and excepted 92 cents, the rest they write off and ge a tax break on. EOB's are very interesting reading. I would bet each medicare doc is paid a fee to except medicare patients in his area whether they ever see one or not, just like HMO's. That's how they can afford to except the negotiated price.

Call medicare and ask if can turn your pump off because he doesn't like having to write of fhte negotiated difference. How did he used to get his meds and what has changed? The concentration may increase and that increases the cost but that makes it last longer between refils.

This is wron g but I know people who have had pumps whos docs won't go above 2 mgs of morphine a day, or 5 mgs, or pick some arbitrary number like other docs put on long acting meds. I never considered it was due to the price of the med.

 
Old 01-07-2009, 01:01 PM   #5
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Re: Medicare/Pain Pump

can you find a another DR to refill it for you and pay cash??? how much is your medication? is it to expensive? if so you might have to go back on oral medications which probably don't work great for you since you have the pump. this is a nightmare gosh I Am sorry.

you may want to search on healthboards under the insurance info help, perhaps they can offer you some sugestions on how to deal with medicare and your Dr. good luck! SS

 
Old 01-07-2009, 02:30 PM   #6
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Re: Medicare/Pain Pump

Slipperyslope: Thank you for your post. The cost of my fentanyl refill on the Syncromed II pump is $3000 every 3 months which is way to expensive for me to pay under Social Security Disability.

Shoreline: I am going to call Medicare to ask all your questions and see if there is something Medicare can do to discuss the problem with my PM so he will continue providing my pump refills. I've also had BOTOX injections in my back due to muscle spasms, but I had to call my medical insurance company (currently on COBRA for another month until I am Medicare elgibile) and I had to pay for the BOTOX and they classified it as a medical procedure and it went toward my deductible and co-pay instead as a prescription but the medication was shipped directly to the PM office. I did talk to my PM about other injection procedures such as BOTOX and ESI; etc. and the only problem he is experiencing with Medicare paying for the medication under Medicare Part B is the pain medication (especially fentanyl) for the pain pump .

My PM said he has absorbed the cost difference on his pain pump patients this whole year and he cannot continue to absorb the cost difference (My PM is the only doctor in the group so it is a small office which he cannot make up the difference because he cannot perform enough procedures to offset the cost difference). In my area, there are only 3 PM doctors who performed pain pump procedures and 1 has already stopped providing service; my PM is going to stop the service; and the other PM is also thinking about stopping service due to this problem with Medicare. I tried talking to my PM that I would pay the cost difference but Medicare requires the doctor to absorb the cost and it is against Medicare laws for the doctor to charge the patient for the difference (I verified that issue through Medicare).

I really appreciate everyone's help on this issue and I just want to make everyone aware of this problem before having a pain pump implant so they do not end up in the situation I am facing now.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
Old 01-07-2009, 03:03 PM   #7
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Re: Medicare/Pain Pump

Shoreline: I just called Medicare and they advised me, a physician office can stop providing treatment as part of their practice and it does not affect their status as a Medicare provider. I asked the question why Medicare does not pay the cost of the medication and the agent has forwarded the question to a Medicare department(I can't remember the department name) which handles these types of problems and questions and are suppose to call me back. I will let you know what Medicare says when they call me.

I just hope I can get this problem resolved quickly as my PM has already begun decreasing my pain pump level every 2 weeks so I will not go through withdrawl when he removes the pain pump.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
Old 01-07-2009, 11:17 PM   #8
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Re: Medicare/Pain Pump

Hey Lisa, Even if he won't supply the meds, Dont have the pump removed. He's using a big unbrella to cover an isolated problem. Of course a doc doesn't have toprovide service, people wopuld complain their doc won;'t ghive them pain meds or diet pills. But this wqs done with medical aproval and demed medically nexecesarry. Even if he won't refill it, It can be turned off for a few months untill you find a new doc. Medtronics will ghive you a list of everyone in your state. I know one poster, it's been awhile since she posted, but she had to go through 5 different pump docs to ofind one that would adjust it to a rate that worked. The first 4 had some random numbeer they wouldn't exceeed. She needsded more so she found a new doc.and had been happy ever since. Unfortunately this happens and people are disapointed with the results and have them removed. Buthey can turn it iofoff, way down and make one fill of saline last a year. Having it removed only to find there was a doc a few miles away would suck.

Although a doc has a right not to provide specific treatments. Implanting a pump borders on the comitment made by both particpants could be considered a verbal contract. He had the uper hand, He is being compensated, he just doesn't like it so now jhe wants another 5K to take it out when someone else can take over management.

Asfar as memedicare, I wouldn't drop it. Too many people take that first nothing can be done answer and give up. You would be surprised how far yo can get by simply saying thankyou and call back and talk to someone that does see what's going on. He had to have writtena letter ofmedical necesity to have a pump implanted. meaning orals didn't work, caused too many side effects etc etc. I can't imaging why they wouldn't want to know why they are spending 30K. I thiink you can find someone that will see the problem and ccreate a loop=hole for items that required a verbal comitment so great it has to border on a contract. He's totally bailing and I have a really hard time he isn't actually paying that much for the meds. That's retail and docs don't opay it. Insurance won't poay it and I would be shocked if it actually cost more than a couple hundred bucks.

Changing the subject, I never tried getting aproval to try botox in my back, It is mFDA aproved for use in the neck with the right DX codes and my happens to have them so Part B pays for it. She does have to order it herself through a mail order pharamcy but gives the docs addy to ddeliver too and to handle the billing. At first he tried the it's a prescription thing, But it's used in a medicalprocedure. It would be like telling a patient to pick up the anesthesia for their operation at the hospital. A little paralytic, a little hynotic tttranq and some very potent pain med, most likely one of the fents.
There is no way they will ship that to an individual and that's what they told my wife. Botom line, her HMO has a contract and he has agreed to a certain amount and has to stick to it. If he didn't want to go there, he could have never offered it . Why put you through the trauma of a surgery and risks associated with it because he's loosng a couple hundred bucks how often?

If you pick up scripts or see a NP,,Thery bill the same code as if you are seeing a doc, Isn't he recording he wrote that script and some type of contact was made. Even if they just sit you in a room and have a nurse bring you the script. It's a billable apt. Docs crying the blues about rembursem,ent, Just lok at the car he drives and rethink how unfair it is if he loses a few bucks on your pump refill, How myuch does he make each time he turns it down. I know there is a billable code for that from having apts to turn it up. Either way its a calabration and adjustement. So he's making it up now and giving you no choice. He knows who else uses pumps in your area. Even if its rural,,He knows who in the city does pumps If you have a synch 2 you culd go as long as 6 mmonths on the right concentration. He got his training and certification somewhere. Medtronics was great about thew whole thing. I would even tell them why you need a new doc. How big is your resevoir and whats the concentraion. I know my doc will tell me what it actually costs and what he might loose on that. I don't need your doage, just the med and concentration. my next refill is Feb 10 or something, but I can get a good idea then. Opiates are very cheap in bulk wolesale form. Yours are being a compounded by a pharamcist to the desired concentration , plus it has to be preverative free, so each dose is made fresh and the greater expense is the pharamcist and shipping. This is just so wrong.

If I could post the cost of pharamcutils per kilo as listed in a journal from AARP it would blow your mind. It's astonishing what the % of gross mgin is. The largest markup on any of the 50 drugs listed was Xanax at over 5000,000% yep, a half million% markup. At a couple bucks a kilo to several dollars per a mg, .05 mg or .25mg your talking serrious profit and hundred million dollar saleries for pharma CEO and CFO and presedents. That was namebrand but in general the markup on a generic is even higher than a name brand.Why can't you switch from dilaudid or morphine?
If you have the large resevoir and you can't manage the pain I would be calling the manufacturer tomorow and making apts. It could take several months to get into a large enough practice or hospital PM program. But you may be surprised at howmany are out there and certafied by medtronics to implant and mange them.
Take care, Dav

 
Old 01-08-2009, 08:01 PM   #9
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Re: Medicare/Pain Pump

Hi Shoreline:

I have been in contact with Medtronics several times and have even sent them a copy of the the email from my PM where he states his problem with Medicare and is forced to remove patient pumps. I tried contacting Medtronics again today as someone in their Marketing Department was suppose to contact me and try to find a resolution for this problem but I have never received a email or call. I told Medtronics I was extremely upset with their response to my problem since the cost of the pain pump was very expensive and I felt with the cost of the pump I should at least receive customer support.

One of the problems of going to a physician outside of my area is I am joining a Medicare Supplement Insurance company which is an HMO and I will be restricted to only the doctors in their group. Note: I will not have Medicare coverage until April 1st as it will be my 29th months being on SSD. The reason why the pain pump medication problem is affecting me now is I have to go through a series of decreases in my pain pump medication level since the PM will not perform the next pain pump refill in mid-April.

I have sent a proposal to my PM today saying I will give them a deposit for the fentanyl if they will allow me to at least have one refill under Medicare with the Medicare Supplement Insurance Company. We can then see how the insurance company processes the refill claim and make the final decision if the pain pump medication is covered by the supplemental insurance company or if the pump will need to be removed. I am praying right now he will give me at least one try with the insurance because it is hard to argue a problem with Medicare and the supplemental insurance companies without a claim because nobody will tell me what the benefit will pay unless I have a claim on the pain pump refill. It is terrible how you can't get any information until after you have a procedure and then learn how much you have to pay!!!!!

The State Insurance Department has contacted a Dallas Medicare Center and they are going suppose to call me tomorrow. I know it is impossible to change Medicare policy but I am going to give tell them how it is affecting pain patients which will have to live in extreme pain without the pain pumps and try to appease to them how it would affect them if they are in the same situation. I know Medicare does not care about people but only money.

I know if I have to go back to oral pain meds, I will have to watch the cost of the retail amount of the meds, and I know I will not be able to afford the fentanyl patches as it will exceed the $2700 Part D limitation only after a couple months due to the high cost of the patches.

Hopefully, I will hear some news tomorrow which I can update you on this saga. I am trying to advocate for the pain pump patients because if it is affecting my area, it might affect the physicians in your area soon unless something can be done now to get Medicare to pay for our pain pump meds.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
Old 01-08-2009, 08:05 PM   #10
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Re: Medicare/Pain Pump

Shoreline: I forgot to mention when I talked to the PM about keeping the pain pump but not to refill it the next time and he said what he has to do is to fill it with saline so the pump will not be running dry. If not, the pump might stop working and the cathether might dry out and clog up. This is an option I am also thinking about but if there is not going to be any PM in my area who are able to refill my pump, then I am better to have it removed as I am afraid of the risk of infections if I am not using it for the purpose it is intended.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
Old 01-13-2009, 05:28 PM   #11
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Re: Medicare/Pain Pump

Shoreline,

I thought I would update you on my problem with the pain pump medication on Medicare. I received an email from the PM Clinical Manager regarding the pharmacy the PM uses is on a Medicare Advantage Plan which I am getting ready to sign up for when I am Medicare eligible in April (due to disability). The Medicare Advantage Plan said I was correct the pain medicine is classified under Medicare Part B and not Part D. I called the Medicare Advantage company about the pharmacy and I advised them I had talked to the pharmacy, about a week ago, and they said they would not process my prescription for the fentanyl under Medicare Part B as they would not incur a loss due to Medicare reimbursing the pharmacy below the medication cost. I aaked the Medicare Advantage company if they had actually discussed the fentanyl cost with the pharmacy and they said they did not since they are under their plan.

I then sent an email to the PM Clinical Manager about the problem with the pharmacy and some questions on clarifying when I should have the pain pump refilled as the manager wanted to refill my pain pump (to do a test claim with the pharmacy) prior to me going to be on Medicare. The Clinical Manager sent me a return email and just went ballistic saying I had emailed her too many times about questions and she was not going to respond to my emails unless it was an emergency. This problem is an emergency for me; but I guess she is not the person who is going to have their pump removed and she does not see the problem as an emergency. Due to not being able to ask questions to my PM office and the uncertainity about the claims being processed with the Medicare Advantage company, I have decided it is not worth the risk to continue with the pain pump and I go next week to start weaning off the pain pump. Also, I have read President Obama is wanting to eliminate Medicare Advantage Plans as they are costing Medicare more money than traditional Medicare Supplement Plans and the future of Medicare Advantage Plan (which may or may not pay for the fentanyl) is in doubt.

My other problem is converting to fentanyl patches after the pump is removed due to the cost of the fentanyl patches are extremely expensive and will exceed the $2700 Medicare Part D cap after 6 months. So I will have to be on low dosage pain medication to try to control my pain level.

I just hope the future of the problems with Medicare will not affect you or any other pain pump patient. I do not know the full scope of the cost difference which the PM is having to absorb; but I hope it will not affect your PM and being able to continue to provide the pain pump as a treatment option. I also talked to Medtronic and they are very concerned about the problem and they are trying to work with Medicare. It might be too late for me before something can be done about the Medicare coverage on pain pump medication but Medtronic and Medicare are aware of the problem and hopefully they can work out a solution.

I will let you know if a miracle occurs over the next 2 months as I am going through the weaning off the pain pump which will allow me to keep my pump as a treatment option.

Thank you for your suggestions and concern.
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
Old 01-15-2009, 12:54 PM   #12
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Re: Medicare/Pain Pump

L5S1,

I read your story with great sadness and anger at the system that is doing this to you. I don't really have anything helpful to add, you and Shoreline are far more knowledgeable than I on this subject.

I just don't want you to give up. Like Shoreline said, the fact that you got the pump must have been preceded by oral meds not working or not being tolerated.

Are there any other docs who you can go to? Even if you have to travel -- could they increase concentration so you could go less often?

It sounds like you've thought of everything, but I just had to respond to at least say I am thinking of you and wishing you the best outcome.

-Wren

 
Old 01-15-2009, 03:49 PM   #13
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Re: Medicare/Pain Pump

Hi Wren,

Thank you for your post and your concern.

I talked to the Medicare Advantage Insurance Company agent yesterday afternoon and tried to find out if their company pays for the difference in the cost of the fentanyl so the doctor; pharmacy; or myself will not have to pay any out of pocket expense. I was advised due to the Privacy Act, they are not allowed to advise the pre-determination of benefits for the pump medication and refill and I would just have to take a chance on the first pump refill under Medicare and their Medicare Advantage Supplement company to find out how the claim is paid. My PM said unless he can get a 100% guarantee he will not lose money on the pain pump refill, I will have no choice but to have the pain pump removed. My fentanyl concentration is 10,000mcg/ml which is a very high concentration and it costs $3000 for just the fentanyl on each refill (which is about every 3 months). The problem with travelling to a PM out of my area if a choose a Medicare Advantage Plan is they restrict you just to the doctors in their network. If I go out of the network, then I am responsible for paying for the full cost of the fentanyl ($12,000/yr plus the cost of the refill procedure). This is just too expensive with my limited income.

I am also limited in PM physicians who perform the pain pump surgery and refill and on PM has already stopped performing the refills this past year due to Medicare not paying for the cost of the pain medication. Also, most PM will not want to accept other PM patients with the pain pump as they do not want to incur any liabilities caused by infections and CSF leaks due to a surgery performed by another PM.

The pain pump is great but there is too many problems with insurance to make the pain pump a viable option for me as I cannot assume anymore financial risk since I am only receiving SSD and LTD income.

I start next week with the weaning process off the fentanyl on the pump and probably will have the pump removed in April. I am still looking at alternatives until then and I just there will be a miracle which will allow me to keep the pump before the PM schedules the pain pump removal surgery.

I appreciate everyones suggestions and appreciate any ideas which will resolve this problem. I just want to make sure that anyone who is making a decision on the pain pump to check out the issues I am having if you are on or going to be on Medicare.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
Old 01-15-2009, 04:36 PM   #14
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L5S1 HB User
Re: Medicare/Pain Pump

I received a letter from Medicare today which outlines the amount of reimbursement for compounded medications for pain pumps. In my situation, my presription is for 10,000mcg/ml for a 40ml pump. The pharmacy advised the cost of the fentanyl is $1050 and according to the Medicare repayment schedule, the amount of reimbursement is $320 for fentanyl concentrations over 5000mcg/ml. This is a loss for either the doctor or the pharmacy of $730 to refill my pump. There is a statement below the Reimbursement Schedule which states "If the cost to the physician is significantly greater than the above reimbursement, a valid invoice may be supplied with a redetermination request. It must indicate a good faith effort has been made by the physician to purchase the drug at a reasonable cost." I have tried to ask my PM billing office how much they get reimbursed but they said it violates HIPAA for them to tell me so I do not know if they are submitting a redetermination of benefits for the cost difference. I also asked the Medicare Supplement Insurance Companies (whether Traditional plans or Advantage plans) cover the cost difference. I have asked the question to the Medicare Advantage Plan company and they will not advise me of the benefit amount under their plan due to HIPAA. I do not know why patients are not allowed to obtain information about benefits to make a determination if they can afford a treatment. I think the biggest problem regarding my problem is due to the fentanyl costing a lot more than morphine. If I was not allergic to morphine, then the Medicare benefit might cover the cost of the morphine.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

Last edited by L5S1; 01-15-2009 at 05:41 PM.

 
Old 01-22-2009, 04:54 PM   #15
Senior Member
(male)
 
Join Date: Jan 2003
Location: OK USA
Posts: 229
L5S1 HB User
Re: Medicare/Pain Pump

I just want to update what I have learned since my last post.

I have talked to a couple PM doctors in my area and they have said they will not take a patient from another PM who has a pain pump due to liability issues and they are expericing the same issue with Medicare on the paying on the pain pump medication. I talked to a PM who is the most well known in my area and they said they have not installed a pain pump in a new patient in over 2 years and they are only refilling the patients who they implanted the pain pump.

I have run out of options and will begin the weaning process off my pain pump to have it removed.

I do not know if the problem with the reimbursement of the pain medication on the pain pump is just in my area but I stongly suggest anyone considering the implant of the pain pump to investigate the problem with getting the refills. It is almost like buying a printer, as the printers are cheap, until you have to buy the printer ink!!!!

I pray nobody will have to lose their pain pump to the problem with Medicare reimbursement on the pain medication.

Take Care
__________________
Spondylolisthesis - level 2 L5/S1
Pars Defect
End Plate Separation
2 Nerve Root Blocks (no effect)
L5/S1 Posterior Fusion with hardware (no BAK cages due to lack of disk space) - August 2002
Right side hardware removed due to loose screw and rod rubbing against facet joint - March 2003
Sciatica returned 8/03 - Tried Neurontin and Elavil - Eased sciatica but could not tolerate medicine.
11/03 MRI of cervical and thorasic spine

 
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