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.

Flaws In Medicare Coding Interpretations

We work with medical oncologists/hematologists across the country in both the private practice and hospital settings. Based on our experience, I'd like to point out a couple of key flaws in the current Medicare code interpretations.

First, several of our oncology physician clients in various states have recently experienced what I consider to be unfair treatment and flat out harassment by local carriers over the topic of “medical necessity”. Local Medicare carriers have taken it upon themselves to “down code” many of these physicians’ visits without foundation (mainly those billed at level V) and send them accompanying letters that are threatening in nature.

We have conducted our own audits on these charges in question and feel that thorough documentation has been provided in every case to warrant appropriate billing. Within a specialty like oncology, we should expect to see high-level coding on a regular basis. The local carriers do not believe these visits met the criteria of “medical necessity”, thus their decision was to “down code”. Their interpretation of the national Medicare regulation is that a level V visit requires a “new medical problem”. We disagree.

We firmly believe these physicians have billed for legitimate services within the published guidelines, and their notes reflect as such. We feel these local carriers are acting wrongly and unfairly. There is no documentation published at either the local or national level stating that a “new medical problem” is required to bill higher level codes.

Over the past few years, we requested numerous ALJ hearings in response to these down-coding situations and have won several of them – one as recent as this month for an oncology practice in Paducah, Kentucky.

That leads me to the second problem needing to be addressed. While we keep winning local ALJ hearings, our physicians continue to get down-coded for the same reasons over and over again. There appears to be no process (or the current process is flawed) for taking these ALJ Hearing victories up the food chain and communicating them to the proper people – so that local carriers can become informed in order to keep these same errors from happening to other physicians. A related issue is that the ALJ victories apply to only the specific charts that the carriers have audited. They then go after more charts for these same physicians, and the process starts all over again. It’s a waste of the physicians’ time and a waste of tax payer’s money.

What should we do to fix this situation?

AMA Rejects Request For New Hem/Onc CPT Codes

Neltner Billing and Consulting recently submitted documents to the AMA suggesting that the infusion coding oncology and hematology rely on for appropriate payment of professional physician work and practice expense is failing in its purpose. Along with those documents we made requests for revised CPT coding to better reflect the work physicians are truly performing.

Unfortunately, the CPT Panel rejected our requests for the following reasons – with which we disagree:
1) They feel the existing E/M codes adequately describe physician services.
2) They feel our proposal lacked specialty society support.

1) We disagree and maintain that the existing E/M codes do not represent the professional work value associated with oncology/hematology treatment planning. They do not include specific bullet points or measures which can be scored to attribute to the level of service indicated. We have evidence that auditors continually fail to recognize the physician work associated with oncology/hematology planning in that levels of service are down-coded because credit is not properly attributed to the medical decision making. Auditors use medical necessity as the overarching criteria for down-coding the level of service, relying on the incorrect premise that a new problem, diagnosis or complication must be present in order to bill a level five service.

Auditors fail to recognize that a comprehensive review and exam combined with the high medical decision-making elements associated with administering drugs that cause extensive toxicity qualify as a level five service – even in a stable, chronically ill patient. The misunderstanding associated with what truly constitutes a level five service provides additional evidence that there is a need for separately reportable codes to identify the treatment planning elements of oncology and hematology encounters. The AMA coding in the infusion coding preamble discusses the highly complex nature of oncology care. Therefore, one code cannot come close to offering evidence of the different levels of care required to identify the correct treatment planning code for different levels of care.

2) With respect to a lack of support from specialty societies, we did receive and review the comments provided by the American Society of Clinical Oncology and the American Society of Hematology. While these societies ultimately don’t support the specific code requests, both expressed agreement with our contention that the physician work is not adequately captured with the existing E/M codes, nor is it included in the drug infusion codes. (Both societies indicated that a single code to represent oncology treatment planning would be more favorable rather than the proposed tiered set of codes.) With due respect, we do not believe that either ASCO or ASH understand what is happening in the community. After all if 95% of their members are under-coding – and hence, devaluing their service – who is going to complain? What we are experiencing is that auditors are looking at level five notes and calling them level three services.

Physicians across the US continue to down-code for fear of audits, and the work to defend their choice of high complex coding is under attack by carriers who use tactics of three formal reviews that will result in a lot work to defend an additional $40 payment per code. Also, these auditors and their processes do not allow a change in policy if you do actually win at the highest appeal. We have specific documentation to support this concern.

That is why we believe new coding with better definitions will resolve the concern.

Where do we go from here?
What we have done is ask the AMA to synchronize our coding request with the coding request proposed in 2004 by the Drug Administration work group (as suggested by ASCO and ASH). We would be pleased to have the Panel consider the proposed codes in a condensed format, represented by some variation of codes, rather than the series of codes originally requested. This would also be more consistent with the perspectives of ASCO and ASH.

We are hoping to hear back from the AMA and request reconsideration for this coding effort to be placed on the February 2010 agenda of the CPT Panel Executive Committee.

Stay tuned.

“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.

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 impending May 1st, 2009 deadline 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 new provisions have created serious new responsibilities for our physician clients as well as potential liabilities (financial and legal).

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

If you need more information about meeting compliance with these procedures contact us, and we’ll help you out. We can also put you in contact with some of the experts we have been working with to address identity theft protection for own employees.

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? Part 2

Where is all the money going? In identifying who is making what profit in the oncology drug distribution system, there are four parts to consider in pricing:

Manufacturer cost: the technological cost to produce, shop, or otherwise bring the drug to market. Their profit margin should be transparent – they know the end user’s profit margin is at a maximum 6%.

Distributor cost: includes acquisition costs, storage costs, and a reasonable profit margin. This margin is 2%, considering their cost is only 1% above the manufacturer cost. ASP (average sales price) does not include this 2% shipping, and distribution cost and this is a permitted cost added on to the ASP.

GPO (group purchase organization) cost: commissioned to help medical oncologists in the community purchase drugs at their lowest possible price. The GPO secures a .25% to .75% discount from the distributor, who would negotiate an even better cost with higher volume. The manufacturer does need to know the demand to appropriately staff and manage production.

Acquisition cost (or Oncologists’ cost): should be ASP less 2% as an industry standard, but in reality, it is typically 4% above ASP.

The Million Dollar Questions
Who is taking the 2% to 4% margin?
Are all these costs necessary?

In the end, the oncologist is suffering from this process. It’s way too complicated.

We would like to hear your thoughts on what process should we engage in to eliminate both the GPO and distributor overhead factors. Simply reply on the “comment” button below. You can provide your name or be totally anonymous. You can also email me (Marty Neltner) at mneltner@earthlink.net.

New Codes May Be the Answer to Evidence Based Medicine

The challenge of oncology is to recognize and establish incentives for the cognitive skills of physicians that will create both cost savings and superior outcomes for both patients and payers.

I recently attended a the world conference on health care titled “Leadership Summit on Evidence Based Medicine” in Alexandria, VA. The major speakers at this meeting were medical directors of insurance companies, think tank experts, Gail Walinsky the prior CMS director and the Institute of Medicine. The overarching conclusion is there is no independent measurement of Evidence Based Medicine. The Institute of Medicine (IOM) issued a compelling report suggesting an independent agency (I thought, “Oh great, another agency to measure nothing”) be established to perform this task. The problem is how to fund it. As you know, private industry, insurance companies and the government are trying to develop this process of Evidence Based Medicine. Everyone agreed whoever funds this will have a difficult task of developing a process that is encumbered by special interest.

As you can guess I was one of few representing the physician interest. I might mention that speaker after speaker referenced the disastrous bone marrow transplant failure brought on by the oncology community. My sense is that this group did not have much respect for what oncology does for its patients on a day-by-day basis. After three days of listening I finally had an opportunity to comment. I am always struggling with what to say to convince those attending there are solutions – if only they would listen to us “privates in the trenches”.

My solution is simple: create level six, seven and eight evaluation and management codes for chronically ill patient care. These codes can be utilized by any physicians in any specialty providing chronic care. This would solve the issue surrounding the failed lobbying for oncology treatment planning codes. Treatment planning never happened (even at our urging with a proposal including detailed documentation) as the AMA RUC Committee has stated oncology treatment planning is recognized in the level five services. The AMA has denied requests for treatment planning at least two times. In my opinion, however, the AMA would accept the argument for level six, seven and eight codes for management of chronic illness. These new codes would reduce health care costs; therefore their value would generate the measurement for Evidence Based Medicine.

The compelling excellent outcome evidence is ever present in oncology care. The problem of course, is the oncology community is not engaged in utilizing the Evaluation and Management coding to prove its worth. Instead, they continue to under code and produce documentation that has no real true measurement. The oncology bell curve unfortunately looks like that of Internal Medicine and Family care. The verbiage in the note is full of ROS and exam points that are negative and without real substance offering data about the current condition of the patient, where we started and the goal of therapy. There is no clear evidence of success and outcome. Yet 99.9% of the patients who pass through the daily offices of thousands of oncology offices tell a different story.

So, the challenge of oncology is to “Change the Wheel” and redirect attention to creating the perfect level five note that will show 70% utilization in every oncology practice. Acquiring this data by year-end will be the calling card to support the need for level six, seven and eight coding that will clearly define the outcome measurement of Evidence Based Medicine. So join the Neltner Marines, board the bus and get ready for “Neltner Billing Level Five Boot Camp”. We’ll be posting more about this training that we will conduct. At the end of this training you will have the tools and the confidence to collect what the GAO says you are entitled to. We believe you will be paid for 50% of your value which will lead you to six, seven and eight codes to complete the cycle.

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.

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.

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.

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.

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.