How do reimbursement policies affect oncology care?
The reimbursement policies of Medicare, Medicaid, and private insurers can have a major impact on the ability of oncologists to deliver care to their patients. This article explores current issues of particular interest to
Who do I contact for any reimbursement or billing questions?
Please consult your legal counsel or reimbursement specialist for any reimbursement or billing questions. You are responsible for ensuring that you appropriately and correctly bill and code for any services for which you seek payment.
Do oncologists get paid by insurance companies for chemotherapy?
The oncologists then bill patients’ insurance companies for the treatments, including billing the payer for the cost of the chemotherapy PLUS a percentage based mark-up. Medicare, for example, receives bills from oncologists that charge 106% of the cost of the chemotherapy.
Is the AMA recommending the use of interest fee schedules?
Fee schedules, relative valueunits, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services.
How is chemotherapy reimbursed?
Many chemotherapy drugs are available in injectable forms, which are administered by providers in clinical settings. Provider-administered drugs are usually reimbursed under the medical benefit of an insurance policy instead of the pharmacy benefit.
Do oncologists profit from chemotherapy?
Smith, an associate professor of oncology at the Medical College of Virginia Commonwealth University, has estimated that oncologists in private practice typically make two-thirds of their practice revenue from the chemotherapy concession.
How are oral oncology drugs reimbursed?
Patients obtain oral cancer drugs from specialty pharmacies; insurers reimburse these based on the prices paid to the distributors by the pharmacies.
Does reimbursement influence chemotherapy treatment for cancer patients?
We found no evidence that reimbursement incentives affected oncologists' decisions to administer chemotherapy to metastatic cancer patients. Once a decision to give chemotherapy was taken, however, physicians receiving more-generous Medicare reimbursements used more-costly treatment regimens.
Why do oncologists make so much money?
Doctors in other specialties simply write prescriptions. But oncologists make most of their income by buying drugs wholesale and selling them to patients at a marked up prices.
Why do oncologists push chemo?
An oncologist may recommend chemotherapy before and/or after another treatment. For example, in a patient with breast cancer, chemotherapy may be used before surgery, to try to shrink the tumor. The same patient may benefit from chemotherapy after surgery to try to destroy remaining cancer cells.
What percentage of chemotherapy is oral?
According to the U.S. National Cancer Institute, antineoplastic oral agents now comprise as much as 25% of the 400 chemotherapy drugs due to their ability to reduce patients' burden of care.
What is IOD in pharmacy?
In-Office Dispensing vs Specialty/Mail Order Pharmacies As more oral drugs have become part of standard therapy for many cancers, there has been a recent trend within community oncology practices to establish in-office dispensing (IOD) services or retail pharmacies.
What is an oral oncolytic?
Oncolytics were defined as oral medications used to treat cancer, including targeted agents, antimetabolites, topoisomerase inhibitors, and biologics but not hormonal therapies.
The MPFS and CY 2021 Final Rule
The CY 2021 Final Rule was initially published in October 2020 and included significant revisions to two key inputs to the MPFS reimbursement formula – the wRVU value assigned to individual CPT codes and the conversion factor applied to calculate reimbursement.
340B Program & OPPS Final Rule for CY 2021
The 340B Program requires drug manufacturers to offer qualified healthcare providers substantial discounts on select outpatient drugs. Through the program, health systems have historically benefited financially from reduced drug costs which are not available to other market participants.
The RO-APM
Finalized on September 29, 2020, the RO-APM is similar to a bundled payment and will reimburse providers on a prospective, per case basis for all radiation therapy services provided in a 90-day episode of care regardless of modality utilized.
Medicare Part B Drug Pricing: Most Favored Nation Model
On November 20, 2020, CMS announced the MFN Model, which proposed significant changes to Medicare reimbursement for Part B drugs. Intended to be implemented on January 1, 2021, the MFN Model has since been delayed due to public commentary and legal challenges.
Conclusion
Each of the above discussed payment model revisions and updates has the potential to impact significant portions of revenue derived for oncology services.
How does evidence based medicine help cancer patients?
Adhering to evidence-based medicine and choosing equally effective but less expensive treatments will lower cancer costs and preserve or even enhance outcomes. That belief – that you can lower utilization and costs without sacrificing quality – is at the core of the experimentation taking place with value-based reimbursement for cancer care.
Is cancer care value based?
Value-based reimbursement for cancer care soon will move beyond the experimentation phase and into the realm of accepted and preferred health care payment practices. To get ahead of this change, oncology practices must adapt to payment systems that reimburse them for the value of care they provide to cancer patients, not for the volume of services.
When does CMS require JW modifier?
Effective January 1, 2017, CMS requires the use of the modifier JW to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded.
What happens after a Medicare patient administers a drug?
If after administering a dose/quantity of the drug or biological to a Medicare patient, a physician, hospital or other provider must discard the remainder of a single use vial or other single use package, the program provides payment for the amount of drug or biological
What is modifier 25 for E/M?
E/M visits (e.g., 99201-99205, 99212-99215) performed on the same day as drug administration services are separately reportable with modifier 25 if the practitioner provides a “significant and separately identifiable” E/M service.
What is the National Cancer Data Base?
The National Cancer Data Base (NCDB) is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The interpretation of the NCDB data used in the study is derived from a de-identified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology used or the conclusions drawn from these data by the investigator.
How many women have breast cancer in 2011?
The rate of breast-conserving surgery from 2010 to 2011 was 62% of early-stage breast cancers or 180,000 women. 11 It is estimated that 80% of patients treated with breast-conserving surgery are treated with RT. 12 In 2011, approximately 20% of patients were treated with hypofractionated whole-breast irradiation, 13 and up to 30% were treated at US academic institutions. 14 In real terms, this means 24% (0.3 × 0.8) of patients with early-stage breast cancer treated with lumpectomy were being treated with half the treatments they would have previously received. This means without hypofractionation, approximately 140,000 women each year would currently receive 30 to 35 fractions, equal to 4.2 to 4.9 million fractions. If only 30% of all patients with breast cancer received a Canadian whole-breast hypofractionation schedule of 16 to 20 fractions (with or without a boost), the number of fractions would be reduced to 2.2 to 2.8 million. In Canada, hypofractionated whole-breast RT is already used for approximately 70% or more of early-stage breast cancer cases. 15 In addition, a further reduction in number of fractions is possible with the use of partial-breast irradiation, which usually consists of RT treatments twice per day for 5 days.
Does the free standing model apply to hospital based practices?
The model also only applies to hospital-based practices and would not exactly translate to free-standing centers, but a reduction in the number of treatments may more adversely affect free-standing centers depending on changes in government reimbursement models for free-standing centers.
Is radiation oncology a profit?
Hospital administrators are well aware of the benefit of a healthy radiation oncology program. Radiation oncology could also be a source of profit for an institution dependent in large part on a fractionation-based reimbursement scheme, which would otherwise suffer because of the move to shorter courses.
What is an oncologist?
Oncologists are used to flow sheets and following and charting a wide array of data, including blood counts, coagulation parameters, and liver and kidney function, all during active cancer treatment, and also response measures such as x-rays, scans, and tumor markers.
Why do patients sue their doctors?
Frequently listed as a reason why patients sue their physicians is the patients' perception that their viewpoint was ignored. In an era of extreme time pressure and declining reimbursement, one must still try to listen sincerely to one's patients and answer their questions. The office staff is part of the communication system too, and must be well trained in courtesy, safe triage, and privacy safeguards. To improve informed consent, safe prescription of chemotherapy, and timely and effective management of toxicity, verbal education can productively be reinforced by written and online materials. But a moment of precious time and genuine sympathy can go a long way toward preventing litigation.
What is the leading cause of malpractice suits against physicians?
Delay in diagnosis of breast cancer is the leading cause of all malpractice suits against physicians, and delays in diagnosis of lung and colorectal cancer are among the most expensive in terms of indemnity payment (personal communication, Physicians Insurance Association of America, February 2006). Alleged errors in cases of delay in cancer diagnosis typically involve misreading of pathology slides; breakdown of communication between the diagnostic physician (pathologist or radiologist) and the ordering physician, or between the physician and the patient; or failure to follow a symptom or biopsy a mass after initially negative tests. These claims mostly affect primary care and diagnosing physicians such as radiologists and pathologists, rather than oncologists. Nevertheless, oncologists often become entangled in the cases too, either as part of the usual litigation sweep to involve all physicians providing care, or as expert witnesses.
Do oncologists need to communicate with nurses?
For effective supervision of hospital patients, oncologists depend on communication with nurses. During a busy day, or especially in the middle of the night, it is easy to dismiss a nurse's concern as overreaction. Even if their worry is exaggerated, there may be some grounds for the nurse's uneasiness.
Do you have to apologize to a patient for malpractice?
Evidence also suggests that such an apology is often effective in averting a claim of malpractice. Physicians' impulse too may be to apologize to the patient. 20 Nevertheless, in most states, such an apology may legally constitute an admission of guilt. A few states have passed laws protecting such expressions of sympathy from legal interpretation as presumption of culpability. Except in Colorado, however, these states do not exempt other portions of such a conversation from admission at trial. Thus, even in states with such “I'm sorry” legislation, the physician may need help in framing the conversation, in hopes of bringing psychological relief to the patient without compromising the physician's ability to defend himself against a later claim of negligence. Even in Colorado, with the broadest law, the local medical malpractice carrier (COPIC) has a special program that intervenes in timely fashion and rehearses the physician in an effective apology, for greatest benefit to patient and physician.
Do you need written consent for surgery?
Consent for surgical procedures is clearly an area fraught with medicolegal risk, and protection against claims usually requires written consent that is as thorough as possible. For consent for chemotherapy or radiation administration, however, the criteria are less well defined, and practices vary across the country.
Does the National Organization of Physician-run Malpractice Insurance Sort Cases of Medical Oncologists Separately from
Indeed, the national organization of physician-run malpractice insurers does not sort cases of medical oncologists separately from those of internists (personal communication, Physicians Insurance Association of America, February 2006).