We Only Pay For 'X' Amount of Fractions. But You Want More...

[TheWallnerus]

Let's say Evicore through prior auth and peer to peer will only pay for 28 fractions. However, you don't want to do that for your patient and instead treat with 40 fractions. You bill the insurance company for 28 fractions; however, of course your own in house medical records would show 40 treatments. The example is a prostate case. Is doing more treatments, but not billing for them, against any known guidelines or laws, regarding any payor? Examples would be nice. This seems to be a big gray zone where everyone has opinions but few facts.

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[RADONC4285]

Let's say Evicore through prior auth and peer to peer will only pay for 28 fractions. However, you don't want to do that for your patient and instead treat with 40 fractions. You bill the insurance company for 28 fractions; however, of course your own in house medical records would show 40 treatments.

I assume you mean you'll bill the patient/insurance for 28 and just give the rest for "free"? pretty sure that would constitute billing fraud. Ridiculous I know, but underbilling is same as over billing in terms of fraud.

 

[TheWallnerus]

I assume you mean you'll bill the patient/insurance for 28 and just give the rest for "free"? pretty sure that would constitute billing fraud. Ridiculous I know, but underbilling is same as over billing in terms of fraud.

Of course everyone is going to say this. But no hard real-world examples are ever provided. "Doing it for free" is one way to put it. "Doing what you think is best" is another way to put it. Is providing a patient a free sample of antibiotic billing fraud? Otherwise without the free sample, the insurance company would have had to pay for the antibiotic. Ultimately if non-adherence to an insurance company fraction number guideline is billing fraud by virtue of not medically adhering to the guideline, and totally free from a financial tort, that would seem absurd.

 

[radiaterMike]

I agree with RADONC4285 - I would think that this could be considered insurance fraud. You are offering a service for free which disadvantages your competition. Of course that's now how this works in real life (a shorter treatment option would likely be more to your advantage in retaining patients). Ethically I would not think that there are any issues (from a pure philosophy perspective) and ultimately if this is construed as insurance fraud would a jury agree ? I would not think Medicare has any grounds to take back payment (as they do when other services are considered not medically necessary after the fact)

 

[RADONC4285]

Of course everyone is going to say this. But no hard real-world examples are ever provided. "Doing it for free" is one way to put it. "Doing what you think is best" is another way to put it. Is providing a patient a free sample of antibiotic billing fraud? Otherwise without the free sample, the insurance company would have had to pay for the antibiotic. Ultimately if non-adherence to an insurance company fraction number guideline is billing fraud by virtue of not medically adhering to the guideline, and totally free from a financial tort, that would seem absurd.

No argument here about the absurdity of the situation. Nonetheless, my billers have repeatedly warned me that underbilling/undercoding intentionally is problematic

 

[TheWallnerus]

No argument here about the absurdity of the situation. Nonetheless, my billers have repeatedly warned me that underbilling/undercoding intentionally is problematic

Mine too. They seem to point this out too gleefully TBH.

But is a "no bill" (to pt and ins) an underbill? If no codes are submitted, was it undercoded?

If a tree doesn't fall in the forest, does it doesn't make a sound?

 

[Mandelin Rain]

Mine too. They seem to point this out too gleefully TBH.

But is a "no bill" (to pt and ins) an underbill? If no codes are submitted, was it undercoded?

If a tree doesn't fall in the forest, does it doesn't make a sound?

Give it a shot and let us know how it goes. There always has to be a first.

 

[RADONC4285]

Give it a shot and let us know how it goes. There always has to be a first.

I mean usually you are fine unless there is an audit. They're not going to follow up on every patient to see how many fractions they got. But if there is an audit, that's when you can run into trouble

 

[deleted1116990]

I have a patient with a painful spine met. Evicore is not paying for 3D. They don't care that it has soft tissue extension. They want me to bill as complex isodose.

I am treating to 25 Gy. I contoured a volume, did a 3 field plan, looked a dose to kidney, bowel, cord/cauda, etc.
What exactly am I supposed to do? If I treat based on the plan I did and bill as 2D is it fraud? They won't let me take daily images either. Only weekly ports but I am only doing 5 fractions. WTF. Am I supposed to go back and draw a field on a film with wax crayons? I don't even know how to do that as I did not train in 1987. This is insane.

 

[TheWallnerus]

I have a patient with a painful spine met. Evicore is not paying for 3D. They don't care that it has soft tissue extension. They want me to bill as complex isodose.

I am treating to 25 Gy. I contoured a volume, did a 3 field plan, looked a dose to kidney, bowel, cord/cauda, etc.
What exactly am I supposed to do? If I treat based on the plan I did and bill as 2D is it fraud? They won't let me take daily images either. Only weekly ports but I am only doing 5 fractions. WTF. Am I supposed to go back and draw a field on a film with wax crayons? I don't even know how to do that as I did not train in 1987. This is insane.

Same exact issue

This is a problem imho because ostensibly it's now: if you don't clinically conform to what we will pay, your decision to do something different medically (even if you don't get paid/make zero dollars) is now fraud

It's a perversion of physician autonomy into fraud. Not getting paid? Fine. Not getting paid AND not doing what you think's best or else it's fraud? Not fine.

 

[Ray D. Ayshun]

Just give 39. What's this 40 fx regimen?

 

[metallica81788]

Want to impact patient's lives? Go into big insurance where your decisions/opinions matter, not medicine

 

[radiaterMike]

I have a patient with a painful spine met. Evicore is not paying for 3D. They don't care that it has soft tissue extension. They want me to bill as complex isodose.

I am treating to 25 Gy. I contoured a volume, did a 3 field plan, looked a dose to kidney, bowel, cord/cauda, etc.
What exactly am I supposed to do? If I treat based on the plan I did and bill as 2D is it fraud? They won't let me take daily images either. Only weekly ports but I am only doing 5 fractions. WTF. Am I supposed to go back and draw a field on a film with wax crayons? I don't even know how to do that as I did not train in 1987. This is insane.

they know you do all that work. They just do not want to pay for it.

 

[RadRadRad]

I’ve not tried to give away fractions but would think it would be hard in most healthcare systems. The doctors usually have little control over technical charges. Even free standing centers are often jv arrangements. How do you give away fractions without bill subsequently being dropped by someone beyond your control?

Could you threaten to refer to proton center for hypofrac if they won’t allow standard frac 😂

 

[deleted1116990]

Same exact issue

This is a problem imho because ostensibly it's now: if you don't clinically conform to what we will pay, your decision to do something different medically (even if you don't get paid/make zero dollars) is now fraud

It's a perversion of physician autonomy into fraud. Not getting paid? Fine. Not getting paid AND not doing what you think's best or else it's fraud? Not fine.

So what am I supposed to do about it? Do you bother with the peer-to-peer and appeal charade?
Do you just deliver your 3D plan and bill as 2D anyway?

I need to get this patient under beam. This is a 5 fraction palliative bone met and a waste of my time and my staff's time to argue why we shouldn't be delivering a 1980s treatment while the patient suffers in pain.

How is this not corporate practice of medicine, which is illegal in most states?

 

[ramsesthenice]

i don’t think my opinion really matters, but I suspect as long as you try to conform to what is approved as much as possible you are very likely to avoid getting into trouble with under billing as long as you can show you have the patients interest at heart. I mean, you can’t just decide every palliative case needs IMRT. That would be hard to defend and undoubtedly could be construed as being used for a competitive advantage. But in cases when they flat say no and I get denied on appeal, if it’s really needed I’m going to do it. And lose zero sleep over it.

Needless to say, we are only talking about under billing. You never never never want to ever try defending yourself against over billing.

 

[TheWallnerus]

I assume you mean you'll bill the patient/insurance for 28 and just give the rest for "free"? pretty sure that would constitute billing fraud.

they know you do all that work. They just do not want to pay for it.

But Moonbeam doing the work (and not billing for it) is fraud, just like if a center "does the work" of a free fraction, right?

SO. MUCH. FRAUD.

I took a pretty girl out for dinner last night; told her I'd pay. Turns out there was an issue in the kitchen, meal took a long time to come out, and they gave us our dinner for free. The thing is, I promised the girl I would pay for dinner. I now have an attorney and am suing the restaurant for defrauding me out of paying them!

 

[deleted1116990]

But Moonbeam doing the work (and not billing for it) is fraud, just like if a center "does the work" of a free fraction, right?

SO. MUCH. FRAUD.

I took a pretty girl out for dinner last night; told her I'd pay. Turns out there was an issue in the kitchen, meal took a long time to come out, and they gave us our dinner for free. The thing is, I promised the girl I would pay for dinner. I now have an attorney and am suing the restaurant for defrauding me out of paying them!

You took a pretty girl out for a nice dinner and got it for free? What a guy! I usually eat the cold leftovers from lunch the med onc pharm reps leave behind for dinner.
Yes, the rad oncs trying to do 5 fraction 3D palliative bone mets and shoot a port every day are the waste in our medical system...

 

[maxxor]

Isn’t the real issue with underbilling that it’s functionally an inducement for referrals?

Although I’m not exactly sure how charity care write offs are done but that’s how I’d do something if I had my own imaging center. That way you get a tax write off too.

 

[Ray D. Ayshun]

You took a pretty girl out for a nice dinner and got it for free? What a guy! I usually eat the cold leftovers from lunch the med onc pharm reps leave behind for dinner.
Yes, the rad oncs trying to do 5 fraction 3D palliative bone mets and shoot a port every day are the waste in our medical system...

It's funny re the shoot a port comment. We have the ability to be more accurate or precise, and in many cases choose not to because it costs extra. Sounds like something's wrong with the game, not the player. If we as a specialty were explaining to lay folk what a linac can do, including obi, and one said, "so you can see the target every day before you shoot it?," I feel like the rest of the conversation would sound like Tom simkowski and the bobs.

 

[deleted1116990]

It's funny re the shoot a port comment. We have the ability to be more accurate or precise, and in many cases choose not to because it costs extra. Sounds like something's wrong with the game, not the player. If we as a specialty were explaining to lay folk what a linac can do, including obi, and one said, "so you can see the target every day before you shoot it?," I feel like the rest of the conversation would sound like Tom simkowski and the bobs.

I think the problem is that there is even the option to reimburse for a 2D treatment without image guidance to begin with and set some arbitrary lower reimbursement for that antiquated treatment technique. Can't we just set the floor as 3D with daily imaging as a bare minimum?

And instead of the letter that Evicore sends to the patient now that basically implies your doctor is a ***** quack trying to make yacht payments by overbilling your insurance company for something unnecessary, they instead can write the patient an honest letter that says, "

We don't feel it's necessary to pay for any technique or effort, even though they may be very simple, by your doctor to try and protect the parts of your body that don't need to be radiated because your cancer is so advanced you will probably die before you experience problems from being over radiated. You might experience worse side effects during treatment, but this is temporary and the treatment will still work to improve your pain. We have determined all of this from a review of your medical record and disagree with your doctor's assessment and plan even though he has personally examined you. Enjoy the rest of your short life. You should really be thankful we are allowing you to be treated at all. You could always pay cash if you wanted.

Sincerely,
Evicore"

 

[metallica81788]

We don't feel it's necessary to pay for any technique or effort, even though they may be very simple, by your doctor to try and protect the parts of your body that don't need to be radiated because your cancer is so advanced you will probably die before you experience problems from being over radiated. You might experience worse side effects during treatment, but this is temporary and the treatment will still work to improve your pain. We have determined all of this from a review of your medical record and disagree with your doctor's assessment and plan even though he has personally examined you. Enjoy the rest of your short life. You should really be thankful we are allowing you to be treated at all. You could always pay cash if you wanted.

Sincerely,
Evicore"

Brilliant! I might print this out and give it to patients for their appeal. Or at least send it as part of my documentation before the peer to peer.

 

[TheWallnerus]

as Dan Longo might say, a pyrrhic victory

 

[medgator]

as Dan Longo might say, a pyrrhic victory

They're ok with you working for free.

 

[deleted941485]

as Dan Longo might say, a pyrrhic victory

Do not bill who? The company or the patient because technically the extra service was not covered.

 

[TheWallnerus]

Do not bill who? The company or the patient because technically the extra service was not covered.

Bill neither insurance nor patient. At least that's the plan. I sure as heck would not bill the patient even if I could (I am not in charge of billing), and we already knew the insurance company would deny the extra fractions.

 

[deleted941485]

Bill neither insurance nor patient. At least that's the plan. I sure as heck would not bill the patient even if I could (I am not in charge of billing), and we already knew the insurance company would deny the extra fractions.

If the service isn’t covered you could though.

 

[jondunn]

Interesting

Guessing there is a compelling reason for you to stick with conv fractionation scheme for this patient?

 

[elementaryschooleconomics]

Healthcare in America in 2022 is wild. American RadOnc is wild.

Radiation was discovered, we found out it could kill things. We first used the Spicy Rocks™ to kill things, then we made machines. We could kill things without touching people, like in the comic books.

Simultaneously, some teachers in Dallas figured out they could pool their money together in case they got sick and needed to go to the hospital. This was back in the day when people knew "medicine" wasn't synonymous with "insurance".

Things snowballed, as they often do. The iPhone was invented. We figured out how to get Spicy Rock™ level precision with our machines. Insurance somehow came to mean medicine, and folks with oily mustaches and three-piece suits learned how to amass fabulous wealth from other people getting sick.

But only the right people are allowed to amass wealth. Somebody made a graph once which showed some RadOnc doctors made more money from the better radiation. Doctors are allowed to be in a certain range of wealth, but they need to know their place. In order to appease the oily mustache Overlords, we engaged in grassroots self-flagellation, hoping we could make ourselves bleed so badly the government couldn't recognize our hemorrhaging faces. You think face recognition struggles with a mask? You should see what happens with 3 inches of congealed blood.

So here we are, making this thread, asking this question. A doctor wants to do a treatment. Insurance says no no no, we practice the medicine 'round here, not you, friendo. The doctor says fine, I'll do my treatment for the lesser reimbursement of the other treatment, sound good?

Chaos. Fraud. Violence. Entropy.

If you insist on curing cancer, you buffoon, you must do it our way, for our price. You went to medical school? What's your point? You want a pat on the head? Get back to work, and make sure you use the 2022 CPT codes, not the 2021 codes, or we'll audit you into the ground.

 

[madchemist89]

Spicy rocks are trademarked?

 

[thesauce]

This is actually a good and tricky question.

On one hand, you are billing for 28 fractions and you gave 28 fractions…followed by 12 more for free. So from that viewpoint, it would seem fine.

BUT

Imagine that you decided to do 10 fractions of palliative radiation therapy, but 5 of them were billed as SBRT…and then you gave the next 5 for free. THAT is probably illegal.

 

[ramsesthenice]

This is actually a good and tricky question.

On one hand, you are billing for 28 fractions and you gave 28 fractions…followed by 12 more for free. So from that viewpoint, it would seem fine.

BUT

Imagine that you decided to do 10 fractions of palliative radiation therapy, but 5 of them were billed as SBRT…and then you gave the next 5 for free. THAT is probably illegal.

Yes, what your scenario suggests is over billing. That will never end well.

You can in reasonably good consciousness treat a patient with SBRT and bill for VMAT/IMRT since in reality SBRT is a form of IMRT. But the opposite is much trickier. There is a pretty clear (billing) definition of what constitutes SBRT and if you don’t do it and then bill for it…no bueno.

 

[Newquagmire]

There is a pretty clear (billing) definition of what constitutes SBRT

Is there?

 

[TheWallnerus]

There is a pretty clear (billing) definition of what constitutes SBRT

Is there?

I didn't want to say anything

Not super clear IMHO. Lots of wiggle room. We had the discussion a while back; "I know it when I see it," the old p0rn0graphy argument. Anyone's opinions about conformality, inhomogeneity, immobilization, etc., are just that: opinions. You can not find a requirement per se for any of these things in any billing guidelines (read on).

Originally, the definition was straightforward:
Stereotactic Body Radiation Therapy (SBRT) is an emerging treatment method that utilizes externally generated high dose ionizing radiation in certain cases to inactivate or eradicate (a) defined target (s) within the body. The target is defined by high resolution stereotactic imaging. In addition to the radiation oncologist and/or neurosurgeon and physicist, the process may involve input from other surgical specialists. SBRT performed using immobilization technology and a stereotactic image guidance system can be performed in a limited number of sessions, up to a maximum of five. To qualify for SBRT, a high dose should be delivered in a single fraction or in 2-5 fractions. 500 cGy (5 Gray) is considered the minimum dose as a ‘high dose’ for SBRT. A more typical dose would be 1400-2500 cGY (14-25 Gray) if given in one fraction.

But then this specificity was deleted:

Now the definition is VERY wordy, and could possibly entrap the unsuspecting...

To illustrate, if you have ever done SBRT for a newly diagnosed lung cancer and these Medicare clinical criteria were not met, you have committed fraud:

1. Primary [lung] tumors ... when the following criteria are met:
   
   1. Early stage primary tumors in medically inoperable patients OR ...
   2. Early stage primary tumors in high operative risk patients...

The patient didn't want surgery, but he was technically medically operable and not high risk, and you did SBRT... fraud. SBRT on any medically operable Stage I patient could be construed as fraud in the eyes of Medicare.

The hard cutoff at 5 fractions is silly! It's certainly not based on any known magic, 5-fraction radiobiology. I really want to blame a very stupid or ill-informed rad onc who sat in a RUC way back when who's saddled us with this 5 fraction nonsense, but I don't know who he or she would be.

 

[ramsesthenice]

Is there?

Clear maybe an overstatement but by no stretch does the scenario put forward come close to reasonable interpretation even with black belt level hand waving.

 

[TheWallnerus]

Clear maybe an overstatement but by no stretch does the scenario put forward come close to reasonable interpretation even with black belt level hand waving.

I don’t necessarily disagree with you, but consider this angle…

In your best medical judgment you consider 10 fraction SBRT to be the best course of treatment…

Five- Versus Ten-Fraction Regimens of Stereotactic Body Radiation Therapy for Primary and Metastatic NSCLC​

But you know if you bill 10 SBRT fractions you’ll get zero for the whole course. So you just bill five, and don’t bill the other five. Right now it’s fraud. I guess. Under APM, it wouldn’t be.

The medical literature and billing literature are constantly at war with one another in rad onc (and the medical literature NEVER wins). It’s dispiriting.

 

[thesauce]

You can in reasonably good consciousness treat a patient with SBRT and bill for VMAT/IMRT since in reality SBRT is a form of IMRT.

SBRT is not necessarily a form of IMRT. I have been granted SBRT treatment, but denied IMRT planning, and had to come up with a 3D plan for the SBRT treatment. That’s happened a lot of times actually.

Honestly the one good thing in APM was not being tied to any specific modality (the rest of the APM was garbage though)

 

[TheWallnerus]

SBRT is not necessarily a form of IMRT. I have been granted SBRT treatment, but denied IMRT planning, and had to come up with a 3D plan for the SBRT treatment. That’s happened a lot of times actually.

Honestly the one good thing in APM was not being tied to any specific modality (the rest of the APM was garbage though)

Would you have been willing to do the imrt plan and not bill it. I would. I am sure rad oncs who maybe made a habit of something like this would be doing right by their patients, but losing their departments a lot of money.

Of course you would probably have to jump through the fraud hoops (oh you’re doing an imrt plan and not billing it? That’s fraud) like I did.

 

[ramsesthenice]

"I know it when I see it," the old p0rn0graphy argument.

That’s a pretty good analogy actually. My catholic grandma in her mid 90s would consider content that easily makes it onto cable TV these days as full on porn. If you trained in the 2D era, pretty much everything using IGRT, stringent immobilization, and a small number of treatments could be interpreted as SBRT.

Take short course for rectal. At most, I see Bridgerton where some old timers honestly see Debbie does Dallas ☹️. The eye of the beholder matters to some extent I guess.

 

[jondunn]

I think at the very bare minimum the 5 fraction rule
Holds, so in the example that was posed, billing SBRT for 5 fractions and then doing more fractions after Would not be something I would do

 

[ramsesthenice]

SBRT is not necessarily a form of IMRT. I have been granted SBRT treatment, but denied IMRT planning, and had to come up with a 3D plan for the SBRT treatment. That’s happened a lot of times actually.

Honestly the one good thing in APM was not being tied to any specific modality (the rest of the APM was garbage though)

Wow. I have never come across that. That requires an epic leap in logic. SBRT is predicated on conformality so if one deems SBRT is acceptable it’s a little hard to see how they can simultaneously decide IMRT is not. But we know, the system is designed to maximize flexibility to the payers, not the players. I’m with Walrus on how I’d be inclined to handle it.

 

[thesauce]

I think at the very bare minimum the 5 fraction rule
Holds, so in the example that was posed, billing SBRT for 5 fractions and then doing more fractions after Would not be something I would do

NO ONE would do it

 

[thesauce]

Wow. I have never come across that. That requires an epic leap in logic. SBRT is predicated on conformality so if one deems SBRT is acceptable it’s a little hard to see how they can simultaneously decide IMRT is not. But we know, the system is designed to maximize flexibility to the payers, not the players. I’m with Walrus on how I’d be inclined to handle it.

Anything the insurance companies can come up with to deny any portion of your payment, they will. "We will grant you SBRT, but tie your arms behind you back to come up with a safe plan." I had had these types of refusals with intact RCC even - it's a real PITA.

 

[ramsesthenice]

Anything the insurance companies can come up with to deny any portion of your payment, they will. "We will grant you SBRT, but tie your arms behind you back to come up with a safe plan." I had had these types of refusals with intact RCC even - it's a real PITA.

Here is my confusion for this case though: SBRT bills significantly more than 5 fx IMRT. So what’s the logic to approving the more expensive modality? In my neck of the woods they constantly deny SBRT but then say IMRT is ok. Seems like that approach would have them reimbursing less. Obviously, there is something I am missing.

Not gonna lie, I happily use this to their disadvantage with some regularity. When I really want IMRT for palliative cases, I put in a request for SBRT knowing they will reject it but tell me IMRT is ok.

 

[Ray D. Ayshun]

If you do 8 fx lung, can you bill for 5 sbrt and not charge the other 3?

edit: nvm, jd mentioned that idea, which is a good one.

 

[thesauce]

Here is my confusion for this case though: SBRT bills significantly more than 5 fx IMRT. So what’s the logic to approving the more expensive modality? In my neck of the woods they constantly deny SBRT but then say IMRT is ok. Seems like that approach would have them reimbursing less. Obviously, there is something I am missing.

Not gonna lie, I happily use this to their disadvantage with some regularity. When I really want IMRT for palliative cases, I put in a request for SBRT knowing they will reject it but tell me IMRT is ok.

There are charges for planning and then there are charges for treatment delivery. They will occasionally approve SBRT treatment delivery, but not IMRT planning charges. And sometimes they do it the other way around. Basically whatever they can weasel out of.

 

[TheWallnerus]

Here is my confusion for this case though: SBRT bills significantly more than 5 fx IMRT. So what’s the logic to approving the more expensive modality? In my neck of the woods they constantly deny SBRT but then say IMRT is ok. Seems like that approach would have them reimbursing less. Obviously, there is something I am missing.

Not gonna lie, I happily use this to their disadvantage with some regularity. When I really want IMRT for palliative cases, I put in a request for SBRT knowing they will reject it but tell me IMRT is ok.

You can plan an SBRT 3D or IMRT. For some insurances, a 77295 and 5 SBRTs costs less than a 77301 and 5 SBRTs. Nickel and diming.

 

[ramsesthenice]

There are charges for planning and then there are charges for treatment delivery. They will occasionally approve SBRT treatment delivery, but not IMRT planning charges. And sometimes they do it the other way around. Basically whatever they can weasel out of.

You can plan an SBRT 3D or IMRT. For some insurances, a 77295 and 5 SBRTs costs less than a 77301 and 5 SBRTs. Nickel and diming.

Thanks guys. I understand the variables. I just haven’t worked in a situation in which they would come out ahead doling out SBRT delivery charges instead of IMRT planning charges. In our network at our ivory tower, SBRT delivery reimburses better than IMRT planning charges and they are quick to use the latter to try to get out of the former. The opposite is believable, but hard to wrap my brain around. I’ve lived in my own matrix so long, I don’t know that my mind can accept your version of the matrix.

 

[medgator]

Yes, what your scenario suggests is over billing. That will never end well.

You can in reasonably good consciousness treat a patient with SBRT and bill for VMAT/IMRT since in reality SBRT is a form of IMRT.

Nope. As @thesauce alluded to, I've had a few ****ty payers only approve 3D planning for an sbrt case. Ended up using a conformal arc plan for a lung case.

The sbrt planning and delivery charges are discrete