Thursday, December 13, 2007

Reimbursement of Administering Chemotherapy is at a Low Level

Unfortunately, professional services for medical oncologists and hematologists administering chemotherapy and other infusables are getting reimbursed at a low level.

Oncology infusion codes are still using technical descriptors based on 1985 to 1989 CPT codes, which present their descriptors as a “nurse only” type of service. This does not take into account the knowledge, years of training and experience the physician has. We believe the infusion codes must take this into consideration.

Radiation oncology has treatment planning codes, and medical oncology should as well. Or even better yet, the capability to bill level six, seven and eight codes.

Are you receiving the reimbursement needed to take care of your patients, much less just cover your costs of chemotherapy? What are you experiencing? Share your comments with us. We would like to know.

Monday, November 5, 2007

Persistence Pays Off: A Success Story Worth Discussing

On behalf of a client, we have a great success story to report. One of our oncology clients was having continued denials with a large private pay insurance company. Regarding this particular situation, the oncologist was following AMA coding guidelines, however, the insurance company did not agree. The issue at hand was relative to CPT 96413, used for initial drug infusion, along with CPT 96416, used for chemotherapy administration via IV infusion (when patients are sent home with a pump).

The physicians were doing chemo and charging the administration and chemo fee. The insurance company told them only one charge could be “initial”, and that they would not be able to bill these codes together on the same day for the same patient. This started in October of 2006. They received continued denials. We exhausted the official appeals process for this physician. We then participated in a conference call with the insurance company and their legal department. The results of that call were still negative. We provided them with more information and documentation.

Fast forward a year later. They reversed their decision. We won. The oncologist won. Reimbursements will be made retro to January of 2006. This was a huge win for a solo practitioner. Persistence pays off.

If you have success stories please let us know what they are. We will share them.

Wednesday, October 31, 2007

Where Does the Money Go?

In response to the comment on our post “Considering Solutions for Oncology Drug Purchasing”, we agree and that is why we are pushing into new directions in this area. The key ingredient we need is for small groups to band together to arrive at a critical mass to break up this price fixing between the distributors. Medical Oncologists were supposed to be able to purchase drugs at ASP and it's not the case. Right or wrong, our government says it is our responsibility to find the solution. With that said, we have three goals:

Goal 1: Attempt to find a way to purchase drugs at ASP,

Goal 2: If that fails, accumulate the data and visit CMS with specific information,

Goal 3: If CMS and government fail to act on the data we accumulate, then we collectively take legal action to prove that price fixing is occurring in the market.

These are the choices in a free market system. Call us and join our effort.

Thursday, October 25, 2007

Reality is in the Results, and It is No Surprise

In our previous post, “Considering Solutions for Oncology Drug Purchasing”, we asked for you to fill out our short “worksheet” in the News area of our website. We had several responses from oncology/hematology practices, comparing what they are paying to the Medicare allowable. No surprise: most physicians are paying way too much. We have posted these current results on our Neltner Billing website, and will update this as we get more data from hematologists/oncologists across the country.

Now that you see the data, is it reality or myth that:
  • Oncologists cannot purchase drugs at ASP or lower.
  • Oncologists have been misled by industry representatives that oncologists are purchasing drugs at or below ASP.

The answer is reality, and you are proving it in your numbers. The table shows that most payments are red and blue. Red numbers denote payments of ASP+6% or higher; blue numbers denote payments between ASP and ASP+6%. There are few numbers in black which actually fall below ASP.

Thank you for the responses we have received so far and please keep them coming. It is clear from what we have collected so far, that ASP is flawed. The more data we can collect, the stronger we will be in lobbying for change. The data, the reality, cannot be ignored.

If any of you would be interested in attending pre-scheduled airport meetings, please comment back to us as we have considered this as a venue to discuss the ASP issue together in person.

Wednesday, October 10, 2007

Considering Solutions for Oncology Drug Purchasing

Thank you for your comments on the recent ASP post. Oncologists need to band together and find a solution to this problem.

Yes, this is doable. We need to create and engage in a process that suggests finding a solution in a free market system.

Medicare will never hear our plea for better reimbursement unless we can prove with documentation and examples that:
1. ASP is not working and why.
2. The current coding system is not properly reimbursing you for your cost.

How do we prove this to Medicare?

Who can purchase drugs at ASP or lower? You know that many of you are unfairly purchasing at ASP or higher. Following are some points to investigate in proving our case to Medicare:

1. How can we determine that the ASP formula is flawed?
2. Are distributors, GPO (Government Printing Office) and manufacturers taking more profit from the ASP formula than what they should be taking? Would the government agree?
3. Is it true that distributors obtain 2% plus from the manufacturers that are not counted in the ASP formula? If this is true, do distributors need to take another 4% profit from their customers?
4. Why hasn’t One Oncology launched its product? We are told that distributors will not sell to them and this interferes with the free market system. So, who is responsible for stopping this from working?
5. Have the manufacturers, distributors and GPOs misled their customers by making them think they are purchasing drugs below ASP, when in fact the customer is buying below ASP + 6% (huge difference)?
6. Isn’t the GPO supposed to help practices save money?
7. Aren’t we all supposed to purchase drugs at ASP?

Share your thoughts and ideas so we can collectively find the solution. On our Neltner Billing website, we have posted a short “worksheet” in the News area that will enable you to compare the Medicare allowable to what you are actually paying. You can fill it out, fax it back to us anonymously and we will build a spreadsheet with the results we receive. I think this is the type of real data we need to start lobbying.

Our next post will include a sample letter and instructions on writing your senators and congress representatives about this issue. We will do the same. If enough oncologists/ hematologists write in, we can create momentum. I think this is the first step in developing awareness.

Thursday, September 20, 2007

Myths and Realities in Oncology Drug Purchasing

The price of oncology drugs is sky rocketing and reimbursement for them has continued to fall. This may be hurting your practice more than you know. What are you paying for your drugs as compared to the Average Sales Price (ASP)? Do you know the Medicare allowable for these drugs? If you cannot answer these questions, what you don't know may be hurting you.

What person would enter into a business where:
· 85% of his/her product has a margin less than 2%?
· The cost of the product is paid in not less than 90 days?
· The product purchase price requires a huge cost of labor to support the product and has a bad debt of not less than 5%?

Probably no one. Now, let’s take a quiz.

Reality or Myth:
· Oncologists cannot purchase drugs at ASP or lower.
· Oncologists have been misled by industry representatives that oncologists are purchasing drugs at or below ASP.
· Many oncologists are now faced with hundreds of thousands of dollars in debt using the “buy now and pay later” leverage.

If you answered “myth” once and reality twice, you are in the same boat as many of your colleagues. The unfair practices occurring in oncology drug purchasing are putting small private practice oncology groups out of business as we speak. Within our client base, we are finding that several small oncology/ hematology practices and solo practitioners are ending up in the red relative to the purchase of their oncology drugs.

At the helm of a Midwest billing and consulting firm that works with many oncology practices, I intend to continue to investigate what is happening here.

Smaller practices and solo practitioners don't have the purchasing power of larger practices. Therefore, they pay higher drug prices. That does not seem fair. The Medicare allowable for these drugs is ASP plus 6%. Medicare's payment is 80% of their allowable. While this may seem to come out in your favor, many times it does not and you end up paying for your patients' drugs.

There is a difference between purchasing drugs at ASP and at ASP + 4%, 5% or higher. Many oncologists think they are purchasing drugs below ASP, when in fact, they are purchasing drugs at ASP + 6% or 7%. Yes, there is a difference. Calculate your complete numbers and see what you are really paying. Don’t rely on certain drugs with their rebates that come later.

The free enterprise system suggests you, the oncologists, must figure out the process to purchase your drugs at ASP. Is that your job? The perfect world would be when every oncology practice can buy at ASP – because no one would be offering a drug cost below ASP. We’d all be on a level playing field.

So now that we have identified the problem, what is the solution? Share your thoughts by clicking the comment button below.