Medical Oncologists and Meaningful Data

This blog post is Part I in a series on the topic of “meaningful data”.

Any of us working in Medical Oncology know that the Evaluation and Management (E&M) guidelines are not specialty specific, and that the treatment planning of infusion therapy is considered part of a visit. We know that this “suggests” that the majority of visits in a medical oncology physician office should be a level V service.

However, if we use the Physician Quality Reporting Initiative (PQRI) as the starting point for determining meaningful value, we see we have no less than 10 meaningful data points to begin adding to the note to help confirm the value. For example, if staging and line of therapy are added to every note, each has points that add value to the complexity of the note. If this is done in less than six months, medical oncology will have the perfect level V note as well as the demand for the level VI thru IX note.

Let’s take a quick look at the current state of the oncology business.

GPOs and Sales Margins
Mergers and takeovers are everywhere, from US Oncology becoming McKesson, to P4 Healthcare being purchased by Cardinal Health. And Oncology Supply has so many layers of overhead within their GPO structure, it’s no wonder medical oncologist can’t buy drugs at ASP. Contrary to what everyone says about the market, the system was designed so that every medical oncologist should be making at least a 6% margin on its drug purchases.

Don’t be confused on drug sales margins – the sales margin actually needs to be 18% when considering the low reimbursements on the services. Do medical oncologists continue to under code? The answer in my opinion is an obvious “yes” when you look at the national bell curve.

The national bell curve is 5% at level II, 38% at level III, 48% at level IV and 9% at level V. Our audits at Neltner Billing and Consulting (based on reviewing oncology notes) show that the oncology bell curve should be 70% at level V, 20% at level IV, 10% at level III and no level II visits.

Stay tuned in my next blog post for more information on this topic. Check out our in depth Billing Brief article How the Business of Oncology Drugs Relates to Meaningful Data For the Medical Oncology Practice (Part I of III) posted on our website, www.neltnerbilling.com. Let us know your comments.

“Red Flags” Rules Deadline Postponed

The deadline for the “Red Flags” Rule has been postponed to November 1, 2009. The FTC decided to delay the deadline in order to give businesses additional time to educate themselves, review their procedures, and develop their implementation plans.

If you need help in understanding how to protect the identities of both your employees and patients, please contact us for assistance. We’ve already reviewed and implemented our procedures and we can help put you in touch with some of the experts to help you do the same.

Are Your Medical Practices Compliant With the “Rules”?

We are reaching out to all our readers in the medical field to alert them about the August 1st, 2009 deadline (recently extended from May 1st) associated with the “Red Flags” Rule enforced by the Federal Trade Commission (FTC), as well as compliance with the Fair and Accurate Credit Transactions Act (FACTA).

You may know that in order to fight identity theft (the fastest-growing crime in the U.S.), Congress added new sections to the federal Fair Credit Reporting Act (FCRA) when it passed FACTA in 2003 — in which privacy, limits on information sharing, new consumer rights to disclosure and accuracy are all addressed.

While the American Medical Association (AMA) has sought exemption from compliance for physicians and medical organizations, the FTC recently made it very clear that industry-based exclusions are not allowed.

These provisions have created serious new responsibilities for our physician clients as well as potential liabilities (both financial and legal).

What does this mean for our industry? By August 1st, you need to have formal, written procedures in place outlining how you plan to protect the identity of both your own employees and your patients.

If you need more information or have not met compliance for these procedures, contact us for assistance.

We can also put you in touch with some of the experts we have been working with to address identity theft protection for our own employees at Neltner Billing.

The V Coding Trap

We believe there are many flaws in the coding arena and want to discuss one in particular we believe is a trap. Don’t fall into it.

Be aware when using the chemotherapy V Codes (V58.11 or V58.12) or you may not get reimbursed properly for what you are really owed.

Cancer patients have lots of problems, and their treatment if often complex. We firmly believe that “there is no such thing as a routine chemotherapy”. Therefore, oncologists/ hematologists need to assess patients when they arrive for their chemotherapy – to be sure they are stable enough to have their treatment that day. Typically, this assessment would constitute a Level IV or Level V visit. We find this to be true with 90% of the patients in the practices we work with across the country.

Unfortunately, by reporting the V code as a primary diagnosis as required by some local coverage determinations, you are essentially saying the only reason for the encounter was to administer chemotherapy, thereby indicating the evaluation and management service was not necessary and should not be paid. In essence, you’re telling them “Don’t’ pay me” when you do this.

So, how do you get paid for your physician assessment and the chemotherapy? We bill cancer diagnosis as the primary code plus the V code as the secondary, and our clients are getting paid. We’ve not had denials doing it this way. If you use the V code as the primary code, you risk not getting reimbursed for your assessment.

Are You Paying Attention to Your Fee Schedules?

Have you reviewed your fee schedules lately to determine if you’re getting proper reimbursement for all your services? Now is a great time to take a look at what you are doing and make appropriate changes for 2009.

We have found on a regular basis that physicians are miscalculating their non-Medicare fees, which means revenue they are due is slipping through their fingertips. Here are some steps to take to help you determine if the private payers are reimbursing you at a fair rate.

1. Measure and Document What You Can Control
< Determine your total overhead expenses. Separate physician work (including physician salaries and benefits as well as any bonuses) and practice expense (including staff salaries/benefits, space expenses, office supplies and medical supplies).
< Calculate your cost per RVU. Calculate cost for visit services; calculate cost for treatments and procedures; calculate total cost per treatment.
< Compare your practice revenue with your costs (be sure to include Medicare and non-Medicare).
Preforming this exercise once per year will help you set practice benchmarks and sound measures for decision-making.

2. Review What’s Going On Outside Your Practice
Now, you’re ready to review your current private pay fee schedules to determine whether they measure up to your current costs.
Here are some tips:
< What should you expect as payment from non-Medicare payers? We believe at least 30% above Medicare.
< Should you utilize the “loaded” Medicare fee schedule as your basis for negotiating a contract with non-Medicare payers? We think not. Rather, use the unadjusted RVU data, because the geographic adjustment factor could potentially lower your payment.
< Should you accept the non-Medicare payer contracts as is? No! Rather, “calculate and negotiate”. If you document what your reimbursement should truly be, you have more leverage to negotiate with payers. You should include the following: data for expenses – need to be sure yours are covered; data that illustrates you need to be reimbursed at least “X” amount of money and why; tell them at what rate other payer contracts are reimbursing – then compare.

For an example of how to calculate Fee Schedules, visit neltnerbilling.com.

Can Our Healthcare System Finally be Fixed?

Our government spends a lot of time trying to fix our healthcare system implementing policies and procedures that don’t work, make things worse, or sometimes standing idle and not doing anything. We know this because we live the effects of their decisions and indecisions every single day.

But, can creating a competition to finally find the answer that fixes our healthcare system be the key? WellPoint, the WellPoint Foundation and the X PRIZE Foundation are teaming up to create a healthcare X PRIZE because they think so. Who better than health care providers, patients, benefits providers, employers, etc. to change what is broken?

Currently, they are seeking participation from all of us to develop the guidelines for the competition which should be revealed early in 2009. This is a great opportunity to not only be heard on the issues we are living day-to-day, but to initiate the changes that we so desperately need and want.

Visit the X PRIZE site and give them your input and opinion for the guidelines and the areas they should be considering when developing this healthcare X PRIZE competition. http://www.xprize.org/future-x-prizes/healthcare-x-prize

Neltner Billing has submitted the key items we think need to be included in this competition.

The competition has great rewards for the team that achieves the X PRIZE goal based on the guidelines that are input. The X PRIZE Foundation will award a minimum of $10 million to the winning team.

Now is our chance – don’t let this opportunity pass - they are finally asking the right people. Take this opportunity to participate in the decision-making process.

Do Rebates Belong In Healthcare?

Rebates can be a great deal – that is if you’re a retail customer buying a car, a computer or a high-end kitchen gadget. But, if you’re a medical oncologist treating people with serious illnesses, should you have to rely upon rebates to get the best possible price on drugs for your patients? While we love a good deal, we don’t think the practice of rebates belongs in the health care system. In fact, we think they are unfair and are borderline unethical because they can drive physicians to purchase and administer drugs patients may not need. They also, in the end, increase the cost of drugs to the patients.

We think oncologists/hematologists need to put their foot down and fight this issue now.

Here’s an example. If you choose to treat your cancer patients for chemotherapy-induced fatigue with Aranesp, the list price is so high, its counter-rebates and discounts are distorting the real ASP. So, the physician is faced with purchasing the drug 20 % to 35% below his/her reimbursement in anticipation of receiving several rebates and discounts from the distributor and manufacturer - in hopes his/her cost will eventually fall below the Medicare allowable of ASP +6%. The primary problem is the manufacturer list price is making it unaffordable to buy this as a single-source drug. And, Amgen has creatively bundled Aranesp and Neulasta, and physicians must sign a contract requiring them to purchase these drugs together - in order to get the best possible price and the “rebate”. The physicians must also negotiate an additional discount with the distributor.

To make matters worse, effective July 1st, Amgen instituted a price increase on both Aranesp and Neulasta by eliminating the discount with the distributor. When is this going to stop? These issues are making drugs unaffordable, putting patient care at risk and contributing to the exorbitant cost of health care.

What are oncologists, especially small practices and solo practitioners, supposed to do? There are a couple of possible alternatives.

1. write their patients a prescription, and send them off to the pharmacy to purchase their own chemotherapy.
2. send Medicare only and self-pay patients to the hospital.

We think the bundling/rebate practice is unfair and enables drug companies to form monopolies.

For more than 25 years, we’ve successfully represented medical oncologists/hematologists within the private practice, hospital and university settings. Due to the high cost of drugs and the unfair rebate process, several of our small and solo practice clients have been forced to close their doors. Others are currently considering doing the same.

Neltner Billing and Consulting is requesting ASCO to take action on this issue. Physicians should be able to purchase drugs as cheaply as possible in order to provide affordable care to our patients. Stop the rebates. Stop the bundling. Simply focus on getting the cost of the drugs down.

Reimburse Doctors For Their Brains

Ancillary services are causing a major problem in accomplishing health care savings. In fact, it is so bad that many physicians look to joint ventures with hospitals and other entities in order to supplement their income with ancillary revenue. Why? Because “cognitive” services for all physician specialties have gone unrecognized and are not reimbursed. Rather, physicians are compensated for the volume of services rendered as well as ancillary services (i.e., MRI, Pet CT, catheterization and other test ordering).

Why is it that physicians are not paid properly to use their brains and to problem solve for their patients? That is what they trained to do. In my opinion, this is backwards and it’s costing the system a lot of money. Included under the not reimbursed “cognitive services” umbrella are: chronic disease care management, multidisciplinary coordination with other physicians relative to patient care, participation in tumor board conference and cancer committee, pain management while the physician is not present, phone calls related to patient care, pharmacy management, education, etc. While these activities directly relate to patient care and management, they are not currently billable. We think this is wrong.

Specialists are often billing at the same rate as primary care physicians when they should be able to bill a Level IV or Level V for the complex management of their patients. CMS previously tested a model eliminating profits from ancillary services when the Congress passed a bill that reduced ancillary drug payments – from AWP methodology to ASP – then added physician value and extra overhead cost to the new oncology codes. These were adopted by the AMA in 2005. CMS declared success in saving money by this action; however, with the implementation, CMS unfortunately did not add enough physician cognitive value in the new codes. Additionally, CMS continues to audit physicians who document and bill the highest level of visit codes.

We believe the solution to the issue relative to cognitive services is simple. The answer lies with the development of 3 new specific codes (levels VI, VII, VIII) that do not require face-to-face contact to recognize the cognitive services for the care and management of chronically ill patients. These codes could be utilized not only by medical oncologists and hematologists, but by physicians in all specialties when treating their patients. This solution would provide a remedy benefitting the entire health care system and would enable patients to get the quality care they deserve.

Neltner Billing has been trying to solve the cognitive services problem for several years now. We previously proposed treatment planning codes (specific to medical oncology/hematology) to the American Medical Association as a solution, and we were denied. The AMA either needs to embrace those treatment planning codes or adopt the higher level codes mentioned above that all medical specialties can utilize.

We are preparing a white paper to distribute to key congressional representatives and various health care organizations in the next 30 days in order to get our opinion heard on this and other key issues. We really believe that making some fairly basic changes could save the entire health care system money.

Oncology Reimbursement: Where Have the Drug Profits Gone?

A physician called me recently and said, “I am mad as heck and I am not taking this anymore.” He is not making 6%, he is making 2%. He believes the drug distributors are taking too much of a margin on the drugs. Another issue that is of major concern is why are the GPO’s owned by the distributors? Is this not a conflict of interest? If you note that when you switch, two white shirts show up at your door. One represents the distributor and the other represents the GPO. How can one impose savings if the physician is paying for two salespersons, two distribution systems? It is apparent we need some transparency in the game of drug purchasing.

I believe it is time for oncologists to demand some transparency and demand a 6% margin on drug purchases. I would think an investigation is needed to identify what margin of profit the distributor takes and what margin of profit the GPO takes. If they are one in the same company then we have a double dip. Instead of simply giving me the best price, the GPO offers many gimmicks and trickery into thinking you are getting the best price.

It is time to eliminate our current drug pricing methodology. Since 2001, our drug distribution system has convinced oncologists that it is okay to accept a 2% margin, or in many cases a 2% negative margin, on the drugs they purchase. Contrary to what should be happening in the industry, drug representatives are still encouraging physicians to use their drug more frequently. And the current drug rebate programs being offered to oncologists (if your volume is high enough) are an abomination that promotes the mentality of “use our drugs and treat like crazy so you get a rebate.” Forget patient care and the best drug for the patient.

Not only are many oncologists tied into the drug distributors and GPO’s for hundreds of thousands of dollars, they are also trapped and are now paying excessive interest for the 75 day hold.

As we consider all this information, it is important to realize that the perception in Congress is that oncologists are still making excess profits on drugs. Where are the needed dollars to provide the excellent care patients demand? Oncologists aren’t seeing them.

Today’s Oncology Drug Procurement: Effective or in Crisis?

Is the drug procurement process for the cancer delivery system in crisis or is it working?

In Economics 101, the law of supply and demand suggests that as demand increases, supply should follow and eventually the price should decrease accordingly. The customer expects to receive the best value for the product or services received at the lowest price.

But this “price drop” is not a term frequently used in the healthcare industry, especially when we look at oncology drugs. When a patient finds out that they are diagnosed with cancer, there is no goal to compare prices for the best deal; the goal is to be cured.

The patient has no incentive to focus on finding the best price for the product they were prescribed. The patient’s focus is on improving and recovering. The question is who becomes the advocate for the patient to ensure their best interests are being met? Who asks for the prices of Taxol versus Taxotere, Procrit versus Aranesp, Neupogen versus Neulasta?

Believe it or not, oncologists and insurance companies share a common problem. The drug distribution system is depleting precious financial resources from Medicare. But the solution is not to hurt the drug industry, but to instead cut out the waste of inappropriate costs that are added by the manufacturer to the end product.

This will enable oncologists to avoid the enormous debts that they are incurring today because of the price of drugs. The distributors gain security because the likelihood of Oncologists filing bankruptcy or repudiating their debts is lessened.

Is your oncology practice incurring debt due to the costs of drug procurement?

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.