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Are We Winning Yet

Started by TheWallnerus
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TheWallnerus

TheWallnerus

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Clinics that close will be able to give their MDs substantial pay raises if past rad onc salary history is any guide.

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New survey finds Medicare policy changes threaten access to cancer care nationwide - American Society for Radiation Oncology (ASTRO)

Radiation oncologists report double-digit cuts and widespread risk of clinic closures in a national survey
www.astro.org www.astro.org
 
Please, enlighten the unfamiliar European.

What seems to be the issue?

-Are less busy clinics forced to close, because due to reimbursement cuts, the income of a less busy clinic, can no longer sustain its operations?

- Why exactly is there a gap between the quoted 1% cut and the experienced 10% cut?
 
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Palex80 said:
Please, enlighten the unfamiliar European.

What seems to be the issue?

-Are less busy clinics forced to close, because due to reimbursement cuts, the income of a less busy clinic, can no longer sustain its operations?

- Why exactly is there a gap between the quoted 1% cut and the experienced 10% cut?
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~20 rad onc codes present for a decade or more got deleted Jan 2026. ASTRO/ACRO went to CMS and did a complete redefinition of standard external beam codes. IMRT was eliminated as a billable kind of thing except for the IMRT plan. Briefly, the three codes became:
Level 1: electrons and 2D (pays ~$150)
Level 2: single iso 3D or IMRT (pays ~$300)
Level 3: 2D/3D/IMRT multi-isocenter, or motion management, or combined photon electron, or total skin electron (pays ~$450)

Furthermore, each code definition contains the proviso "Includes image guidance." However, there is a new professional-only MD IGRT analysis code (pays ~$30).

Basically level 2 becomes the default most times.

Problem 1: Level 2 bills about 15% less than the old IMRT codes.
Problem 2: The new IGRT analysis code pays hospitals ~5% less for IGRT, but it pays freestanding clinics ~80% less than they had become accustomed to since ~2006.
Problem 3: prior authing the new codes with insurances is an occasional clusterf*ck because they don't have policies for the codes, but still try to deny IMRT e.g. (even though it's not a code)
Problem 4: the rad oncs in America who helped make the codes with the AMA and CMS had no experience with freestanding billing and didn't think any of this through very well it seems

Problems probably only Luigi Mangione can solve
 
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Palex80 said:
Please, enlighten the unfamiliar European.

What seems to be the issue?

-Are less busy clinics forced to close, because due to reimbursement cuts, the income of a less busy clinic, can no longer sustain its operations?

- Why exactly is there a gap between the quoted 1% cut and the experienced 10% cut?
Click to expand...
It's quite simple. Medicare is a giant entitlement program which has a budget that is inexorably spiraling out of control. To control costs, one lever is to slash reimbursement to physicians. Large, naked cuts are politically toxic. Therefore, government bureaucrats fundamentally alter the billing codes that will ostensibly slash reimbursement but gild it with soft language like, "more efficicient coding," "takes away the need for prior authorization," and "payment stabilization."

To further obsucate things, the bureaucrats give a very rosy prediciton as to the percentage breakdown of billing codes and project that physicians will bill the lucractive codes at a high percentage thereby minimizing overall reimbrusement cuts. The reality is the opposite. Practices hemorrhage money, complain, and here we are ...
 
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How’s that ROCR coming along Astro

Back in 2024 we were being told all the major societies were supporting it

Funny thing is Astro did all the code redefinitions. Astro is constantly fouling up. This is is like cutting off your own leg and then declaring an emergency that you can’t outrun your attacker

Astro and the Kanamits… they are just here to serve man
 
Palex80 said:
Please, enlighten the unfamiliar European.

What seems to be the issue?

-Are less busy clinics forced to close, because due to reimbursement cuts, the income of a less busy clinic, can no longer sustain its operations?

- Why exactly is there a gap between the quoted 1% cut and the experienced 10% cut?
Click to expand...
We need a $1.5 Trillion military budget, because Eric and Don Jr. hold multiple defense contracts and Sr. will need to handsomely bribe generals for loyalty when the military coup occurs before the election. Duh.
 
This week:
1. 3dCRT denied for a large pelvic met with soft tissue extension. Overturned on appeal. This one was great, because they sent a denial letter last Friday night, we didn't request a p2p on Saturday, so p2p option not available as you have to respond within 24 hours. Came in on Monday to a denial with no p2p option.
2. PSMA PET scan denied in the initial workup of a high risk PCa patient. Appeal pending. PSA is 92.
3. 77412 denied for an arthritis patient with 4 isocenters. Second appeal pending. No reason given for the denial. Just "we will approve Level 1 but not Level 3".
4. Special tx procedure denied in a patient getting both concurrent chemo and whose RT plan includes overlap c prior fields. Overturned on appeal.
5. Had a patient whose insurance "product" did not cover any chemotherapy or radiation whatsoever. Had to wait to go on her husband's plan in order to start tx. 1 month delay.

This is fun I'm having a great time.
 
OTN said:
This week:
1. 3dCRT denied for a large pelvic met with soft tissue extension. Overturned on appeal. This one was great, because they sent a denial letter last Friday night, we didn't request a p2p on Saturday, so p2p option not available as you have to respond within 24 hours. Came in on Monday to a denial with no p2p option.
2. PSMA PET scan denied in the initial workup of a high risk PCa patient. Appeal pending. PSA is 92.
3. 77412 denied for an arthritis patient with 4 isocenters. Second appeal pending. No reason given for the denial. Just "we will approve Level 1 but not Level 3".
4. Special tx procedure denied in a patient getting both concurrent chemo and whose RT plan includes overlap c prior fields. Overturned on appeal.
5. Had a patient whose insurance "product" did not cover any chemotherapy or radiation whatsoever. Had to wait to go on her husband's plan in order to start tx. 1 month delay.

This is fun I'm having a great time.
Click to expand...
Frustrating

Insurances will approve a $20K course of radiation but flex on a $200 special tx procedure. Weird.

Getting 77412 for arthritis is … difficult
 
TheWallnerus said:
Frustrating

Insurances will approve a $20K course of radiation but flex on a $200 special tx procedure. Weird.

Getting 77412 for arthritis is … difficult
Click to expand...
77412 for multiple isos for arthritis should not be difficult. It is being difficult because they are gaslighting us in a way that none of us should ever accept. It's absurd that people claim multiple isos is not completely clear and cut and dry.

Active motion management has far more room for interpretation but if you're treating multiple ISOs, it's 77412. I don't see any linkage to indication anywhere
 
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$5,000/day x 14 days = $70,000 in payments held at any given time.

Current 10-year T Bill is about 4.3% right now.

$70,000 in T bills = $3,010 yield.


Do this at a massive scale and garner massive profits. **** the patients. Our insurance industry is so evil.
 
NotMattSpraker said:
View attachment 417581
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Yay. Pontifications for pontificating’s sake. What they’re saying may be useful from a Medicare standpoint; completely worthless bloviating from commercial insurance standpoint or even Med Adv. Will have to listen. But Ron is always doing more harm than good with his opinions.
 
TheWallnerus said:
Yay. Pontifications for pontificating’s sake. What they’re saying may be useful from a Medicare standpoint; completely worthless bloviating from commercial insurance standpoint or even Med Adv. Will have to listen. But Ron is always doing more harm than good with his opinions.
Click to expand...

Im curious how many on this board get surveyed about CMS codes or practice expenses.

These guys constantly complain about survey response rates, but Ive never been offered a survey. I asked around my current practice and they have never been surveyed.

Do you have to be a society member to be surveyed? Its funny to me that the discussion of the N is always left out. What is the survey population?
 
TheWallnerus said:
Was this a Medicare Advantage case; if yes, I can explain the reason
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Mandelin Rain said:
Please do so. Just the delay to hold money in investment?
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Ray D. Ayshun said:
If they do this for one PSMA PET per day (presuming it costs them $5000) each day for a year and put the money in t-bills for 2 weeks, by my math they'll make $3000 or so a year in interest.
Click to expand...
I don't ascribe a nefarious "deny and invest" reason to the delay. It's a real banality of evil situation however. Let me make a few observations and lay out a few facts.

If this was a Medicare Advantage case, and there was a 2 week delay, I'm going to assume you appealed. The pathway for appeal for Med Adv is: something doesn't match policy, it is denied, and you can appeal. Then the insurance company usually upholds the appeal. However, CMS pays Maximus, an outside "independent review entity/qualified independent contractor" (IRE/QIC), about $1 billion a year to review ALL Med Adv appeal denials. They do not look at cost and do not look at insurance company policy; they only look at if the thing/test/scan/treatment/DME is general reasonable/medically acceptable. To journey through that denial, then appeal, and then Maximus re-look... takes about 2 weeks.

When Maximus overturns an appeal it affects the insurance company's star rating. This is the most important thing that governs how much an insurance company gets from the feds to run their Med Adv program. The deny/hold-money/t-bill thing would pale in comparison to the money involved with star ratings. It doesn't take much Maximus overturnage to affect a company's star ratings.

TL;DR always appeal every Med Adv denial as the final decision is outside of the insurance company's hands
 
thecarbonionangle said:
Breadlines are definitely coming. Centers will be closed. More practices will sell.
Click to expand...
I mean ... logically, it should happen. But, despite too many of us, despite hypo-fx, despite declining indications, people seem to be doing okay. What makes you think it will be different in 2026? I generally would agree, but the fact that it really hasn't gotten much worse or seen job losses make me question breadline theory. I don't mind being wrong, but if wrong over and over, I am wondering where my reasoning is falling apart.
 
WildRivers said:
I mean ... logically, it should happen. But, despite too many of us, despite hypo-fx, despite declining indications, people seem to be doing okay. What makes you think it will be different in 2026? I generally would agree, but the fact that it really hasn't gotten much worse or seen job losses make me question breadline theory. I don't mind being wrong, but if wrong over and over, I am wondering where my reasoning is falling apart.
Click to expand...
The ASTRO survey respondents said they had to fire physicians. Weren’t making payroll. Losing huge amounts of money. Closings contemplated.

Any concrete evidence that is true? I haven’t seen CONCRETE evidence.
 
I've heard of practices deciding not to hire someone because of q1 revenue. I have not heard of one firing and I know a lotta people and practices! Money is definitely being lost. We are experiencing that but have not discussed for one second letting staff or doctors go. In fact, I had a money saving / labor saving idea that is not even being discussed. For a freestanding center to not make payroll - something else would be off, I don't think this alone would do it. But, maybe it is happening.
 
WildRivers said:
I've heard of practices deciding not to hire someone because of q1 revenue. I have not heard of one firing and I know a lotta people and practices! Money is definitely being lost. We are experiencing that but have not discussed for one second letting staff or doctors go. In fact, I had a money saving / labor saving idea that is not even being discussed. For a freestanding center to not make payroll - something else would be off, I don't think this alone would do it. But, maybe it is happening.
Click to expand...
image.jpg
 
WildRivers said:
I mean ... logically, it should happen. But, despite too many of us, despite hypo-fx, despite declining indications, people seem to be doing okay. What makes you think it will be different in 2026? I generally would agree, but the fact that it really hasn't gotten much worse or seen job losses make me question breadline theory. I don't mind being wrong, but if wrong over and over, I am wondering where my reasoning is falling apart.
Click to expand...

I know of 4 practices that closed this year
 
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WildRivers said:
I mean ... logically, it should happen. But, despite too many of us, despite hypo-fx, despite declining indications, people seem to be doing okay. What makes you think it will be different in 2026? I generally would agree, but the fact that it really hasn't gotten much worse or seen job losses make me question breadline theory. I don't mind being wrong, but if wrong over and over, I am wondering where my reasoning is falling apart.
Click to expand...
Look at the comments in ATRO survey. ASTRO knows this and they say this in private meetings. People will lose their livelihood. Dont despair tho, PPS “nonprofits” stand by to help and consolidate even more. The plan is working as planned. You’re just not in it partner.
 
TheWallnerus said:
The ASTRO survey respondents said they had to fire physicians. Weren’t making payroll. Losing huge amounts of money. Closings contemplated.

Any concrete evidence that is true? I haven’t seen CONCRETE evidence.
Click to expand...
Must all be fake news from misanthropes then. Nothing to see here folks!
 
OTN said:
It's very hard for me to imagine a world where ASTRO is upset about freestanding centers' financial troubles.
Click to expand...
ASTRO has some people who truly care and have the heart in the right place. A battle of ideas is often fought but it is not always won. I did not fully understand it initially but non clinical people like Adler and others in ASTRO intelligentsia constantly shut down good bold ideas in favor of more “realistic” solutions. They may or may not be right in the end but you have to wonder. Society is growing tired of these moderate voices, the people who prefer the stagnancy of order instead of revolutionary bolder thinking. The people get restless. Pitchforks are always right around the corner.
 
thesauce said:
I know of 4 practices that closed this year
Click to expand...
I feel for those centers and their employees and their patients.

If they completely closed down in q1 because of these coding changes, I'm presuming they had larger problems at hand. A center that can't survive after these rough 3 months clearly had other issues. Just my opinion. We are facing considerable losses (more than what people have said in these surveys) and there is no question of closing centers or letting go any staff or physician. It is going to make it harder to get nicer tech or bonuses for us or staff.

That being said, evidence of business closure would be very helpful. If one person knows 4 centers that closed, collectively in a group of 5000 American doctors, I presume we should hear of dozens to hundreds closing during the next year or two. This sort of story would be meaningful and help make our case. I would love to interview these owners and write about it in the Substack. Please message me or email me if your center has closed or know someone that has had a closure and is open to discussing - [email protected]

As far as pitchforks, been hearing this since 2019. It's really hard for people making median RO salary working 4 days a week to go to the toolshed and raise any sort of farming implement.
 
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thecarbonionangle said:
ASTRO has some people who truly care and have the heart in the right place. A battle of ideas is often fought but it is not always won. I did not fully understand it initially but non clinical people like Adler and others in ASTRO intelligentsia constantly shut down good bold ideas in favor of more “realistic” solutions. They may or may not be right in the end but you have to wonder. Society is growing tired of these moderate voices, the people who prefer the stagnancy of order instead of revolutionary bolder thinking. The people get restless. Pitchforks are always right around the corner.
Click to expand...
Even if there are some people in ASTRO who say they care, over the last two decades ASTRO has relentlessly pursued policies which dramatically harm freestanding centers while protecting large health systems.

As Stafford Beer said, there is "no point in claiming that the purpose of a system is to do what it constantly fails to do". While ASTRO can claim it is representing practicing radiation oncologists of all types, in reality ASTRO's purpose has been to advocate for large academic health systems while harming freestanding practice.

Having said that, I do like ASTRO's letter to CMS and request for audience, which I think was the exact right thing to do. I also think it is far too late, but better than never. Maybe having Dr. Kavadi at the helm may help, but he has quite the ship to try to turn around.
 
OTN said:
Even if there are some people in ASTRO who say they care, over the last two decades ASTRO has relentlessly pursued policies which dramatically harm freestanding centers while protecting large health systems.

As Stafford Beer said, there is "no point in claiming that the purpose of a system is to do what it constantly fails to do". While ASTRO can claim it is representing practicing radiation oncologists of all types, in reality ASTRO's purpose has been to advocate for large academic health systems while harming freestanding practice.

Having said that, I do like ASTRO's letter to CMS and request for audience, which I think was the exact right thing to do. I also think it is far too late, but better than never. Maybe having Dr. Kavadi at the helm may help, but he has quite the ship to try to turn around.
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If I’m understand what they are requesting, they want 77407 and 77412 to pay exactly the same.

Fine.

Ostensibly that means external beam has two levels, not three.

Now, if it were me, that’s how I would have designed the system in the first place (presuming bundling IGRT was a forced move from CMS). Because only a very naive individual would presume that prior authing the most expensive code was going to be a walk in the park. Furthermore you define the codes with as simple a language as possible; and you define them to make them “undeniable.” The current code definition suffer a bit from “if you’re explaining you’re losing” energy.
 
TheWallnerus said:
If I’m understand what they are requesting, they want 77407 and 77412 to pay exactly the same.

Fine.

Ostensibly that means external beam has two levels, not three.

Now, if it were me, that’s how I would have designed the system in the first place (presuming bundling IGRT was a forced move from CMS). Because only a very naive individual would presume that prior authing the most expensive code was going to be a walk in the park. Furthermore you define the codes with as simple a language as possible; and you define them to make them “undeniable.” The current code definition suffer a bit from “if you’re explaining you’re losing” energy.
Click to expand...

Multiple isos = level 3

Denied because it's palliative or arthritis

Definition clear as day and they still play games
 
CaesarRO said:
Multiple isos = level 3

Denied because it's palliative or arthritis

Definition clear as day and they still play games
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“multiple isos” is not clear as day to the legion of RNs in America who are triaging rad onc prior auths (mostly because there is not a checkmark box for this on most prior auth forms yet afaik)
 
OTN said:
Even if there are some people in ASTRO who say they care, over the last two decades ASTRO has relentlessly pursued policies which dramatically harm freestanding centers while protecting large health systems.

As Stafford Beer said, there is "no point in claiming that the purpose of a system is to do what it constantly fails to do". While ASTRO can claim it is representing practicing radiation oncologists of all types, in reality ASTRO's purpose has been to advocate for large academic health systems while harming freestanding practice.

Having said that, I do like ASTRO's letter to CMS and request for audience, which I think was the exact right thing to do. I also think it is far too late, but better than never. Maybe having Dr. Kavadi at the helm may help, but he has quite the ship to try to turn around.
Click to expand...
It isnt just academics. There are large community places like US Oncology, Advocate (basically new 21s C), etc which are nothing like the true stand alone center that may actually struggle. These are places building proton centers, etc. I don’t see it as only “academic” places but moneyed elite vs have nots.
 
thecarbonionangle said:
It isnt just academics. There are large community places like US Oncology, Advocate (basically new 21s C), etc which are nothing like the true stand alone center that may actually struggle. These are places building proton centers, etc. I don’t see it as only “academic” places but moneyed elite vs have nots.
Click to expand...
Harder to find mom and pop freestanding centers kinda like Mom and pop med onc shops when you need 7 figures of capital to buy drugs before you start practicing
 
TheWallnerus said:
“multiple isos” is not clear as day to the legion of RNs in America who are triaging rad onc prior auths (mostly because there is not a checkmark box for this on most prior auth forms yet afaik)
Click to expand...
If it makes you feel any better I was doing a prior auth for Abiraterone the other day and the person on the phone asked me how to pronounce “metastasis”
 
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