Holy Lack of Transparency Batman!

[Chartreuse Wombat]

Price Transparency for Prostate Cancer Radiation Therapy at National Cancer Institute–Designated Cancer Centers

This economic evaluation of prostate cancer radiation therapy costs at National Cancer Institute–designated cancer centers assesses the value of the price transparency mandate of the US Centers for Medicare & Medicaid Services in allowing patients with prostate cancer to shop by price for...

jamanetwork.com

Posted in different thread.

Discuss!

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[RickyScott]

1)Obtain pricing advantage by name/geography/exemption
2) buy out or build out more satellites and expand the faculty
3) increase resident numbers as non monetary compensation for ever expanding faculty
4) again increase prices with larger footprint and even more leverage with insurance.
5) achieve “price transendency” where rates so high, that can still turn profit offering protons at imrt/3D rates.
(Or justify proton expense to “defend” lucrative ebrt)

 

[Mandelin Rain]

It’s gross.

Lately, I’ve been having a harder and harder time rectifying my participation in the health care system. This is just another data point.

Whichever academic center is billing 400k for 28 fractions should legitimately have people led out in hand cuffs.

 

[Neuronix]

I don't know why that article doesn't have a supplemental table listing center and $ value to go with the figure. If that's truly publicly available data, such a table would be easy enough to generate on this forum.

 

[Mandelin Rain]

I don't know why that article doesn't have a supplemental table listing center and $ value to go with the figure. If that's truly publicly available data, such a table would be easy enough to generate on this forum.

Would be worth the effort.

 

[BobbyHeenan]

Chargemaster data not always indicative of what you actually get....but the principal is there.

If someone can get good data on what people are actually getting/billing insurance then that would shed more light. It's my understanding that that particular data is held up in court appeals to be made public (or not).

I can't even imagine the Choose Wisely memes we'll see if it comes out that 28 fraction prostate at X NCI center costs more than double a 44 fraction plan at a community cancer center up the road. I'm fine with academic centers charging a little more, so in theory they have some money to run trials and do the academic heavy lifting...but major discrepancies I'm not OK with.

An idea for a study would be to take all places enrolling in NRG GU-005, so presumably good enough to pass muster on a linac QA check and has all modern equipment and meets dose planning constraints...so at least some objective quality....and then list out their cost per fraction.

 

[Mandelin Rain]

Can you explain how the chargemaster would differ greatly from actual charges? My impression is that the master would just list all the CPT codes you'd typically bill for the service and multiply them by whatever number.

 

[BobbyHeenan]

Can you explain how the chargemaster would differ greatly from actual charges? My impression is that the master would just list all the CPT codes you'd typically bill for the service and multiply them by whatever number.

I'm definitely not an expert here, but I *think* the charge master is say the "cash price" you would charge.

I think the real meat here in the data is what medicare and private insurance is actually paying you. And that data may certainly correlate with the charge master, but maybe not always.

For instance, for pro fees we charge 3x medicare allowable for patients without insurance or those "paying cash." Otherwise, we have negotiated rates with private insurance companies. However, in my 6 years now in practice I have never had a cash payer, and anyone that I am "charging" that rate on I have never received that kind of payment (typically uninsured and we don't send to collections...so we don't get paid but I "charged" them that).

Someone else please weigh in here that is more knowledgeable.

Also in this study I believe most of these are academic centers, so though there are rumblings out there that academic >>> private for payments, we're yet to see hard data on this. However I suspect the phenomena posted above by RickyScott is real...and typically a strategy in my experience by big academic centers but large community centers/hospital systems may also play that game.

 

[RickyScott]

insurance rates are negotiated and hidden by NDAs and less than chargemaster and Medicare pays cms rates for pts with straight medicare.
True transparency will come if mandate to disclose actual rates next years survives legal challenges

 

[firewicket]

The chargemaster is the pre-insurance charged amount. The contractual payment amount can vary greatly...The kicker in this difference is that hospitals can deduct it as a business loss and decrease tax burden...thus there is an incentive to artificially increase you stated chargemaster amount...also probably why they are so wildly elevated in terms of cost.

 

[Mandelin Rain]

The chargemaster is the pre-insurance charged amount. The contractual payment amount can vary greatly...The kicker in this difference is that hospitals can deduct it as a business loss and decrease tax burden...thus there is an incentive to artificially increase you stated chargemaster amount...also probably why they are so wildly elevated in terms of cost.

Right. They still actually charge that huge number. They just get paid at the negotiated rates and write the rest off as a loss for tax purposes.

None of us actually get what we charge. But none of us have the gall to charge 400k for 28 fractions.

 

[firewicket]

Ohhh...and professional services (AKA private practice contracted rad/oncs) can't do this write off thing by the way...in case you were wondering.

 

[Mandelin Rain]

Ohhh...and professional services (AKA private practice contracted rad/oncs) can't do this write off thing by the way...in case you were wondering.

Wouldn't that be nice.

 

[RickyScott]

I recently had head and neck from out of the country who went to another center. With large discounts, estimate for the radiation was 150,000+. Was going to post the letter with name blacked out. Our hospital charge much closer to Medicare rates.

 

[deleted1002574]

No way! There is no way this is possible. Because then everyone would charge the highest possible rate and then write off millions in taxes. I’m very skeptical. Any documentation of this or any evidence?

The chargemaster is the pre-insurance charged amount. The contractual payment amount can vary greatly...The kicker in this difference is that hospitals can deduct it as a business loss and decrease tax burden...thus there is an incentive to artificially increase you stated chargemaster amount...also probably why they are so wildly elevated in terms of cost.

 

[Mandelin Rain]

NCI designated center employee posits private private/community centers MAY be charging more than 400k for 28 fractions.

 

[deleted18755]

No way! There is no way this is possible. Because then everyone would charge the highest possible rate and then write off millions in taxes. I’m very skeptical. Any documentation of this or any evidence?

Agreed can somebody demonstrate hard evidence to support this? Otherwise, why not charge $1 million per fraction (I know it sounds absurd and unbelievable but so did $400,000 for a course of EBRT for prostate cancer until I saw it in print in that paper. . . does anybody know if there is actually an upper limit on how much can be charged for anything? ) and get whatever you normally get then right off everything as a loss.

 

[Reaganite]

Agreed can somebody demonstrate hard evidence to support this? Otherwise, why not charge $1 million per fraction (I know it sounds absurd and unbelievable but so did $400,000 for a course of EBRT for prostate cancer until I saw it in print in that paper. . . does anybody know if there is actually an upper limit on how much can be charged for anything? ) and get whatever you normally get then right off everything as a loss.

This issue came up in my practice years ago. Inquired about writing off unpaid patient copays and was told "only hospitals" can do that. Perhaps they can write off the unpaid portion of the contracted amount which cannot be done in freestanding?

 

[scarbrtj]

I recently had head and neck from out of the country who went to another center. With large discounts, estimate for the radiation was 150,000+. Was going to post the letter with name blacked out. Our hospital charge much closer to Medicare rates.

Guarantee that whenever Sultan bin Salman or whoever from the middle east goes to ~Mayo Clinic he pays $200+K for his prostate IMRT.

 

[BobbyHeenan]

Guarantee that whenever Sultan bin Salman or whoever from the middle east goes to ~Mayo Clinic he pays $200+K for his prostate IMRT.

I think you meant to say prostate protons.

 

[RickyScott]

I think you meant to say prostate protons.

They provable wouldn’t want to risk giving proctitis to a huge potential donor.

 

[scarbrtj]

I think you meant to say prostate protons.

ha, well he goes for the protons, gets a price quote of a half $mil, and haggles for some nice, cheap imrt

 

[Mandelin Rain]

@ABRO copped my hyperbolic statement. To be clear, I'm not ABRO. But, in a way, we're all ABRO.

 

[lhl]

Somewhat separate from the idea of writing off unpaid charges (which likely only applies to hospitals because they are typically non-profits and thus provide a certain amount of "charity care") is the idea of who charges more for services. The idea that free-standing centers charge less on a global level or are more cost effective does not appear to be evidence based. Although those who argue that free-standing centers get less per fraction are correct, what they often fail to mention is that the same free-standing centers treat with more fractions and use more expensive forms of radiation. On the whole, this leads to higher costs per course of treatment at free-standing centers (at least within the medicare population):

With all this being said there is likely a wide continuum of billing practices in both the hospital and free standing setting and i'm sure there are both "good actors" and "bad actors" in both domains.

https://www.hhs.gov/sites/default/files/CMS-5527-P.pdf
Page 51 of the rationale/proposal for RO-APM:

"Our analysis showed that from January 1, 2015 through December 31, 2017, HOPDs furnished 64 percent of episodes nationally, while freestanding radiation therapy centers furnished the remaining 36 percent of episodes. We intend to make this data publically accessible in a summary-level, de-identified file titled the “RO Episode File (2015-2017),” on the RO Model’s website. Our analysis also showed that, on average, freestanding radiation therapy centers furnished (and billed for) a higher volume of RT services within such episodes than did HOPDs. Based on our analysis of Medicare FFS claims data from that time period, episodes of care in which RT was furnished at a freestanding radiation therapy center were, on average, paid approximately $1,800 (or 11 percent) more by Medicare than those episodes of care where RT was furnished at a HOPD. We are not aware of any clinical rationale that explains for these differences, which persisted after controlling for diagnosis, patient case mix (to the extent possible using data available in claims), geography, and other factors. These differences also persist even though Medicare payments are lower per unit in freestanding radiation therapy centers than in HOPDs. Upon further analysis, we observed that freestanding radiation therapy centers use more IMRT, a type of RT associated with higher Medicare payments, and perform more fractions (that is, more RT treatments) than HOPDs."

 

[deleted1002574]

Well, that sure is interesting. I would love to see the raw data. I wonder if it is such a strikingly high amount, why they wouldn't make the data available or in published form.

Somewhat separate from the idea of writing off unpaid charges (which likely only applies to hospitals because they are typically non-profits and thus provide a certain amount of "charity care") is the idea of who charges more for services. The idea that free-standing centers charge less on a global level or are more cost effective does not appear to be evidence based. Although those who argue that free-standing centers get less per fraction are correct, what they often fail to mention is that the same free-standing centers treat with more fractions and use more expensive forms of radiation. On the whole, this leads to higher costs per course of treatment at free-standing centers (at least within the medicare population):

With all this being said there is likely a wide continuum of billing practices in both the hospital and free standing setting and i'm sure there are both "good actors" and "bad actors" in both domains.

https://www.hhs.gov/sites/default/files/CMS-5527-P.pdf
Page 51 of the rationale/proposal for RO-APM:

"Our analysis showed that from January 1, 2015 through December 31, 2017, HOPDs furnished 64 percent of episodes nationally, while freestanding radiation therapy centers furnished the remaining 36 percent of episodes. We intend to make this data publically accessible in a summary-level, de-identified file titled the “RO Episode File (2015-2017),” on the RO Model’s website. Our analysis also showed that, on average, freestanding radiation therapy centers furnished (and billed for) a higher volume of RT services within such episodes than did HOPDs. Based on our analysis of Medicare FFS claims data from that time period, episodes of care in which RT was furnished at a freestanding radiation therapy center were, on average, paid approximately $1,800 (or 11 percent) more by Medicare than those episodes of care where RT was furnished at a HOPD. We are not aware of any clinical rationale that explains for these differences, which persisted after controlling for diagnosis, patient case mix (to the extent possible using data available in claims), geography, and other factors. These differences also persist even though Medicare payments are lower per unit in freestanding radiation therapy centers than in HOPDs. Upon further analysis, we observed that freestanding radiation therapy centers use more IMRT, a type of RT associated with higher Medicare payments, and perform more fractions (that is, more RT treatments) than HOPDs."

 

[RickyScott]

Somewhat separate from the idea of writing off unpaid charges (which likely only applies to hospitals because they are typically non-profits and thus provide a certain amount of "charity care") is the idea of who charges more for services. The idea that free-standing centers charge less on a global level or are more cost effective does not appear to be evidence based. Although those who argue that free-standing centers get less per fraction are correct, what they often fail to mention is that the same free-standing centers treat with more fractions and use more expensive forms of radiation. On the whole, this leads to higher costs per course of treatment at free-standing centers (at least within the medicare population):

With all this being said there is likely a wide continuum of billing practices in both the hospital and free standing setting and i'm sure there are both "good actors" and "bad actors" in both domains.

https://www.hhs.gov/sites/default/files/CMS-5527-P.pdf
Page 51 of the rationale/proposal for RO-APM:

"Our analysis showed that from January 1, 2015 through December 31, 2017, HOPDs furnished 64 percent of episodes nationally, while freestanding radiation therapy centers furnished the remaining 36 percent of episodes. We intend to make this data publically accessible in a summary-level, de-identified file titled the “RO Episode File (2015-2017),” on the RO Model’s website. Our analysis also showed that, on average, freestanding radiation therapy centers furnished (and billed for) a higher volume of RT services within such episodes than did HOPDs. Based on our analysis of Medicare FFS claims data from that time period, episodes of care in which RT was furnished at a freestanding radiation therapy center were, on average, paid approximately $1,800 (or 11 percent) more by Medicare than those episodes of care where RT was furnished at a HOPD. We are not aware of any clinical rationale that explains for these differences, which persisted after controlling for diagnosis, patient case mix (to the extent possible using data available in claims), geography, and other factors. These differences also persist even though Medicare payments are lower per unit in freestanding radiation therapy centers than in HOPDs. Upon further analysis, we observed that freestanding radiation therapy centers use more IMRT, a type of RT associated with higher Medicare payments, and perform more fractions (that is, more RT treatments) than HOPDs."

So you can quantify excess ratio and multiply that by workforce to come up with what portion of workforce/salaries is supported by excessive utilization? Because that will vanish at some point with APM etc. example:if avg pt bills 10,000 and these centers are billing 1800 more when they should in fact be billing at least 1000 less ( because costs at free standing should be less than hospitals) -I will need help of those women who are good in math on twitter.
if there is a lot of excess utilization, what’s going to happen to job market when it forcibly comes to an end!

 

[scarbrtj]

freestanding radiation therapy center were, on average, paid approximately $1,800* (or 11 percent*) more by Medicare than those episodes of care where RT was furnished at a HOPD.

Academic center physician: "I am shocked... shocked!... that they are charging $18,164* instead of $16,364 for the radiation therapy in the freestanding centers!"

* (x+1800)/x=1.11; x=16364

 

[lhl]

perhaps my use of the word "charge" was inaccurate...should clarify that I was talking about actual amount reimbursed/paid.

 

[RickyScott]

perhaps my use of the word "charge" was inaccurate...should clarify that I was talking about actual amount reimbursed/paid.

In my neck of woods, insurances have told us freestanding community practice is 3-5x less than nci center, puts cms numbers to shame.

 

[RickyScott]

One step closer: price transparency in healthcare

What price transparency rules would mean to physicians.

www.medicaleconomics.com

 

[Lamount]

In my neck of woods, insurances have told us freestanding community practice is 3-5x less than nci center, puts cms numbers to shame.

Must be true everywhere.

 

[RadRadRad]

So you can quantify excess ratio and multiply that by workforce to come up with what portion of workforce/salaries is supported by excessive utilization? Because that will vanish at some point with APM etc. example:if avg pt bills 10,000 and these centers are billing 1800 more when they should in fact be billing at least 1000 less ( because costs at free standing should be less than hospitals) -I will need help of those women who are good in math on twitter.
if there is a lot of excess utilization, what’s going to happen to job market when it forcibly comes to an end!

Clicked on the link. It was 412 pages

Somewhat separate from the idea of writing off unpaid charges (which likely only applies to hospitals because they are typically non-profits and thus provide a certain amount of "charity care") is the idea of who charges more for services. The idea that free-standing centers charge less on a global level or are more cost effective does not appear to be evidence based. Although those who argue that free-standing centers get less per fraction are correct, what they often fail to mention is that the same free-standing centers treat with more fractions and use more expensive forms of radiation. On the whole, this leads to higher costs per course of treatment at free-standing centers (at least within the medicare population):

With all this being said there is likely a wide continuum of billing practices in both the hospital and free standing setting and i'm sure there are both "good actors" and "bad actors" in both domains.

https://www.hhs.gov/sites/default/files/CMS-5527-P.pdf
Page 51 of the rationale/proposal for RO-APM:

"Our analysis showed that from January 1, 2015 through December 31, 2017, HOPDs furnished 64 percent of episodes nationally, while freestanding radiation therapy centers furnished the remaining 36 percent of episodes. We intend to make this data publically accessible in a summary-level, de-identified file titled the “RO Episode File (2015-2017),” on the RO Model’s website. Our analysis also showed that, on average, freestanding radiation therapy centers furnished (and billed for) a higher volume of RT services within such episodes than did HOPDs. Based on our analysis of Medicare FFS claims data from that time period, episodes of care in which RT was furnished at a freestanding radiation therapy center were, on average, paid approximately $1,800 (or 11 percent) more by Medicare than those episodes of care where RT was furnished at a HOPD. We are not aware of any clinical rationale that explains for these differences, which persisted after controlling for diagnosis, patient case mix (to the extent possible using data available in claims), geography, and other factors. These differences also persist even though Medicare payments are lower per unit in freestanding radiation therapy centers than in HOPDs. Upon further analysis, we observed that freestanding radiation therapy centers use more IMRT, a type of RT associated with higher Medicare payments, and perform more fractions (that is, more RT treatments) than HOPDs."

I clicked on the link. It was 412 pages. Does anyone know what defines an “episode of care”? Are we comparing in some kind of case controlled manner? Ie cost for treating intermediate risk prostate cancer at hospital vs free standing.
Having worked in both environments, my experience has been that I saw way more palliative patients, inpatients, keloids/HO, etc at hospital based practice and more definitive patients at outpatient practice. Wonder if this is accounted for or analyzed. Additionally, I don’t think the hospital gets paid anything for the inpatient fractions...how does that factor in?

 

[radiation]

I think price transparency is a huge problem across both private and academic places. A flaw of the paper is that it does not have a non-NCI centers as a comparison. If you take a look at the chargemasters in California, you'll see that gross overcharges are not unique to academic centers

2019 Chargemasters - OSHPD

Find 2019 hospital submitted Chargemasters, average charges for 25 common outpatient procedures, and estimated percentage change in gross revenue due to price changes.

oshpd.ca.gov

Check out Adventist Health Glendale (picked random hospital at top of list) - 63k for Cyberknife SBRT

And lets not leave out our med onc friends, Ipi is being charged 436K at this hospital!

 

[xrthopeful]

Everyone realizes that charge masters aren’t really what anyone pays right? Just so we are clear.

 

[deleted18755]

Everyone realizes that charge masters aren’t really what anyone pays right? Just so we are clear.

I think everybody (or at least most) do, but it still aligns with the theme of lack of transparency. Why does it exist then, other than to further muddy the water and make things less transparent?

 

[deleted1002574]

The point of the study is that basically transparency by way of charge master is not transparent at all and also completely misleading and useless. A microcosm of many studies in our field.

 

[Chartreuse Wombat]

Chargemasters must have a purpose otherwise they would not exist. I am not an expert but I can think of a few reasons why that they exist.

1) A convenient way to begin negotiations (overpriced but "this is what it costs us")
2) A "standard" that can be used to calculate charity care and use to write down taxes
3) A price that wealthy cash paying patients will be expected to pay

 

[deleted956486]

Chargemasters must have a purpose otherwise they would not exist. I am not an expert but I can think of a few reasons why that they exist.

1) A convenient way to begin negotiations (overpriced but "this is what it costs us")
2) A "standard" that can be used to calculate charity care and use to write down taxes
3) A price that wealthy cash paying patients will be expected to pay

Spot on.

 

[Mandelin Rain]

Does everyone get paid as a % of Medicare reimbursement or do some places get a % of what they charge?

 

[GapCalc]

Chargemasters must have a purpose otherwise they would not exist. I am not an expert but I can think of a few reasons why that they exist.

1) A convenient way to begin negotiations (overpriced but "this is what it costs us")
2) A "standard" that can be used to calculate charity care and use to write down taxes
3) A price that wealthy cash paying patients will be expected to pay

All of these reasons were used (and acknowledged by) the admin at the hospital where I trained. Nothing sounds as good as "$XYZ million dollars donated to care for the community!" but when those dollars are basically Monopoly money...

 

[PhotonBomb]

Chargemasters must have a purpose otherwise they would not exist. I am not an expert but I can think of a few reasons why that they exist.

1) A convenient way to begin negotiations (overpriced but "this is what it costs us")
2) A "standard" that can be used to calculate charity care and use to write down taxes
3) A price that wealthy cash paying patients will be expected to pay

this is exactly the case.

as long as we all understand this, people can stop the hand-wringing

 

[RickyScott]

Nevertheless, geographic university monopolies or huge names like MSkcc or mdacc are charging insurances cos higher rates than anyone else. Why, because they can! ( just like northeren California hospitals on average charge twice that in southern ca) They have more leverage. To argue that they are leaving money on the table is as silly as saying that doubling of residents didn’t badly affect the labor supply. We won’t have the hard numbers until courts settle transparency issues.
But guess who is inflicting the worst financial toxicity? A) whoever has the most leverage.

 

[deleted18755]

Chargemasters must have a purpose otherwise they would not exist. I am not an expert but I can think of a few reasons why that they exist.

1) A convenient way to begin negotiations (overpriced but "this is what it costs us")
2) A "standard" that can be used to calculate charity care and use to write down taxes
3) A price that wealthy cash paying patients will be expected to pay

These sound very reasonable and plausible, can anybody with more "expertise" chime in?

PS: #1 seems very reasonable and nobody is shedding a tear about #3, but as much as #2 seems plausible, it sure is a nauseating realization (a hospital "charges" $400,000 for a course of prostate radiation with everybody knowing it's just a made up number but then actually using that number to claim $325,000-$375,000+in loses or "charity care for the poor" every time they treat a prostate cancer patient with medicaid, no insurance, or whatever.

 

[xrthopeful]

These sound very reasonable and plausible, can anybody with more "expertise" chime in?

PS: #1 seems very reasonable and nobody is shedding a tear about #3, but as much as #2 seems plausible, it sure is a nauseating realization (a hospital "charges" $400,000 for a course of prostate radiation with everybody knowing it's just a made up number but then actually using that number to claim $325,000-$375,000+in loses or "charity care for the poor" every time they treat a prostate cancer patient with medicaid, no insurance, or whatever.

Not Medicaid. Medicaid is not charity.

 

[deleted18755]

Not Medicaid. Medicaid is not charity.

Correct me if I'm wrong (which I very much may be) but don't many of these large hospitals often state that they lose money on caring for the uninsured, and a disproportionate percentage of people without private insurance (aren't they referring to Medicaid?). I always assumed they were calculating the difference between private insurance and medicaid and now wonder if it was chargemaster minus Medicaid.

In any event, any day now these numbers are going to be available to the general public. If we as physicians are confused (and appalled to varying degrees) by them, imagine what will then happen to the average prostate cancer patient's view of hospitals and any of us, or anybody who works in the healthcare field, when he honestly thinks that his insurance paid $400,000 for his prostate cancer radiation? Then imagine the rage when this is multiplied by people on social media or elsewhere with ill intent?

At best, like many of us, it will be clear that there is a whole lot of lack of transparency and shady stuff going on in and among what at least for now is still among the most trusted professions and institutions in society (doctors and hospitals) . . .

 

[xrthopeful]

Oh I agree there is shadiness and lack of transparency in the business of medicine and unaware patients often caught in middle. Rad onc especially is so open to interpretation in things like fractionation that can affect the patient experience and this has historically had little oversight. APM will fix it.

I pretty much try to avoid a patient ever getting a bill for something insurance decided later on not to approve, so it’s a weird thing but a patient is much more likely to get SBRT for an oligomet from me if they have Medicare or Medicaid rather than private insurance, if the treatment isn’t clear cut and obvious in the insurance guidelines. I just don’t want a patient getting a bill for 50k for something that isnt guaranteed to help them. I know patients don’t always have to pay those bills, but the bill itself can be distressing when someone is already experiencing the financial toxicity of metastatic cancer

 

[deleted18755]

Oh I agree there is shadiness and lack of transparency in the business of medicine and unaware patients often caught in middle. Rad onc especially is so open to interpretation in things like fractionation that can affect the patient experience and this has historically had little oversight. APM will fix it.

I pretty much try to avoid a patient ever getting a bill for something insurance decided later on not to approve, so it’s a weird thing but a patient is much more likely to get SBRT for an oligomet from me if they have Medicare or Medicaid rather than private insurance, if the treatment isn’t clear cut and obvious in the insurance guidelines. I just don’t want a patient getting a bill for 50k for something that isnt guaranteed to help them. I know patients don’t always have to pay those bills, but the bill itself can be distressing when someone is already experiencing the financial toxicity of metastatic cancer

I lot of really sad stuff in your post above (just to be clear . . . with regards to the system not you personally and I understand where you are coming from).

One question though: I was always told to think of billing Medicare/Medicaid like submitting your taxes to the IRS, sure you can administer whatever treatment you want and get paid (just like you can put down whatever you want on your taxes and get a refund), but you still need to strictly adhere to the guidelines and better be prepared to defend yourself during an audit.

Just like some deductions or whatever are not entirely black and white, and in any event subject to interpretation and the comfort level of an individual with regards to what to claim and when, I guess there are sometimes when one physician would be more comfortable than another treating with SBRT in a Medicare/Medicaid patient who would be denied by private insurer, but I honestly can't personally think of any specific examples. Can you or others provide specific situations (can even be made up theoretical cases)?

Also, how often does Medicare/Medicaid actually audit something like appropriateness of SBRT? Is it random and really possible for some average practice (where they request repayment of a handful of borderline cases that were administered over an extended period of time) or only after a whistle-blower complaint involving obvious and widespread/multi-million dollar fraud?

 

[Burt Radnolds]

Oh I agree there is shadiness and lack of transparency in the business of medicine and unaware patients often caught in middle. Rad onc especially is so open to interpretation in things like fractionation that can affect the patient experience and this has historically had little oversight. APM will fix it.

I pretty much try to avoid a patient ever getting a bill for something insurance decided later on not to approve, so it’s a weird thing but a patient is much more likely to get SBRT for an oligomet from me if they have Medicare or Medicaid rather than private insurance, if the treatment isn’t clear cut and obvious in the insurance guidelines. I just don’t want a patient getting a bill for 50k for something that isnt guaranteed to help them. I know patients don’t always have to pay those bills, but the bill itself can be distressing when someone is already experiencing the financial toxicity of metastatic cancer

There can be severe financial toxicity in medicare patients as they can be responsible for 20% of the cost of the treatment. There is no yearly out of pocket maximum for pure Medicare, unless you have an Advantage plan. However, those are run by private insurance companies who will make you jump through the same hoops as their non medicare counterpart plans.

 

[scarbrtj]

I lot of really sad stuff in your post above (just to be clear . . . with regards to the system not you personally and I understand where you are coming from).

One question though: I was always told to think of billing Medicare/Medicaid like submitting your taxes to the IRS, sure you can administer whatever treatment you want and get paid (just like you can put down whatever you want on your taxes and get a refund), but you still need to strictly adhere to the guidelines and better be prepared to defend yourself during an audit.

Just like some deductions or whatever are not entirely black and white, and in any event subject to interpretation and the comfort level of an individual with regards to what to claim and when, I guess there are sometimes when one physician would be more comfortable than another treating with SBRT in a Medicare/Medicaid patient who would be denied by private insurer, but I honestly can't personally think of any specific examples. Can you or others provide specific situations (can even be made up theoretical cases)?

Also, how often does Medicare/Medicaid actually audit something like appropriateness of SBRT? Is it random and really possible for some average practice (where they request repayment of a handful of borderline cases that were administered over an extended period of time) or only after a whistle-blower complaint involving obvious and widespread/multi-million dollar fraud?

The most common scenario I am coming across now is the 30/5 regimen for early stage breast cancer.
By all Medicare definitions, which are uniquely American SBRT definitions ("I know you only call SBRT something with up to 6 fractions in the US"... not really, but whatever), this is SBRT.
However, Evicore denies it as SBRT 100% of the time (but do allow it as IMRT+IGRT).
I am OK with that because my billing folks don't get in a twist that I'm billing the same style/type of treatment two different ways in two different "insurance populations." However, I am sure there are many places that would not allow 30/5 on a breast patient because insurance denied it as being SBRT and there'd be some mind-numbingly teleologically inane discussion about whether doing an SBRT-type treatment on someone and not billing it as SBRT is fraud.
Just one of many possible examples. And no, in general there is no Medicare audit. There are RAC audits although I don't hear 'bout 'em much anymore. And whistle-blower complaints are a world removed from an audit. A few years back, my Medicare carrier did come knocking however to recoup about $9000 for sim charges I had done through the years for IMRT... charges done because I was completely unaware (up 'til that point in time around 2016) that one couldn't bill a sim for IMRT. One of the touchstones of all our training, the basis for all proper radiotherapy, and one day Medicare says "nope, can't do that." (On the other hand, a setting like that... doing sims that are expressly no-no'd... could have been very ripe fruit for a wannabe whistle-blower. Which is the reason I don't charge a sim hardly ever anymore in any circumstance, not even 3D, because it's just too damn risky IMHO.)

 

[Palex80]

By all Medicare definitions, which are uniquely American SBRT definitions ("I know you only call SBRT something with up to 6 fractions in the US"... not really, but whatever), this is SBRT.

Oh, I'm sorry. It's 1-5 fractions, then?