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TheWallnerus said:
I disagree that this straightens the record.

Breast is the number one indication for RT in America. Prostate is number two (a tie with lung more or less). Protons are radiation therapy. A proforma for ANY radiation center doesn’t work if you exclude the top two primary diagnoses which comprise 50% or more of RT utilization for radiotherapy. Proton centers that don’t treat a good share of the “RT Cancer Market” become closed or bankrupt. Published data has shown the most common indication/utilization for proton beam therapy is breast and prostate… which makes perfect sense statistically and mathematically.
Click to expand...
I think it depends on the center. If you have only protons, every patient looks like a proton candidate.

If protons are "just another modality", maybe your 3rd or 4th machine, you don't have to use it for everyone who walks in the door.
 
IonsAreOurFuture said:
I think it depends on the center. If you have only protons, every patient looks like a proton candidate.

If protons are "just another modality", maybe your 3rd or 4th machine, you don't have to use it for everyone who walks in the door.
Click to expand...

I’m not aware of any center that has only protons. Are you?
 
Star Trek Borg GIF


Is it?
 
Fpg1245 said:
Why do we continue to resist this? Just let protons happen.
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Eat or be eaten! This is why everyone seems to be getting them. Ship has sailed. People love a sysyphus futile fight. My take these days is i’d push anything if it keeps me employed and not in breadlines. I do not have it in me to do another residency.
 
Have people heard of new proton centers coming up? I imagine the appetite to fund them is lower these days.
 
Doctorer said:
Have people heard of new proton centers coming up? I imagine the appetite to fund them is lower these days.
Click to expand...

If you can pay cash or have an endowment they will continue to pop up. It is still a money maker in those situations.

Where places are getting crushed is where VC or bonds or loans are involved. Bond payments are crushing these places.
 
Fpg1245 said:
Why do we continue to resist this? Just let protons happen.
Click to expand...
My bias against protons is clear. I am a never user who has looked relatively deeply at the literature and discussed with multiple proton practitioners... and been basically appalled.

Protons will also function as a further consolidative measure. A 200 bed hospital that is a hub for cancer care in a rural county is not getting protons. Protons take lots of resources, including physics and therapy workforce, and will syphon these resources from smaller centers.

We are advocating for the dissemination of a high cost, high resource utilization intervention that is at best nominally better in certain niche indications.

Let's do the following thought experiment.

Imagine that the first widely disseminated modality for external beam radiation was in fact protons (or any other directly ionizing radiation). The physicists got it to work early, everybody was doing 2 field treatment anyway and the dose depth profile of ions was enough to justify their development.

But....there are intrinsic limitations to particle therapy and the physicist were still dealing with marked dosimetric uncertainties 5 decades later that prohibited meaningful high precision inverse planning, arc therapy or many beam angle therapy, fast patient throughput and affordability.

What would happen in the following scenario?

After a many decade head start, industry started applying advanced planning techniques to a more robust therapeutic radiation called photon therapy. They found that dosimetric calculations could be done very well, including accommodation of tissue density and rapid throughput of iterative planning. They found that you could administer XRT through roughly 360 degrees and modulate easily and dynamically with high density materials and still know where the dose dose was going in a patient.

The tech was also intrinsically cheaper; the infrastructure needed smaller; the treatments quicker.

What I think would happen?

Centers would clamor for the photon therapy immediately. There would be a bottom up movement to enroll in clinical trials demonstrating non-inferiority, which would have undoubtedly been demonstrated.

Radiation centers would become less centralized. Convenience for the patient would improve, with smaller treatment centers being able to offer therapy in rural areas.

By advocating for protons, we are not advocating for progress.
 
Fpg1245 said:
You can’t survive as a physician if you aren’t gaming the system. The system has no problem gaming you.
Click to expand...
This should be on the cover of every medical textbook. The walls of every med school classroom. The first question on every board exam.
 
I wonder that the proton centers without linacs do when say for example a breast patient is getting too much skin toxicity from the protons and switching to photons would make sense. Just do a long break I guess.
 
Thats not my question. I have always heard they don’t have photons. Fake news?
 
I am so sick of patients asking for protons because they saw a commercial on tv. These places need to disclose that pending more data, the use is all speculative. I know they won’t, but it’s very misleading to say the least and I’m an advocate for protons (when it’s useful).
 
thesauce said:
That might be. No regular linac at all?
Click to expand...
I have been to Procure in NJ. They do not have a linac, neither did Indiana University or the other 4 room behemoths. Provision in Knoxville did, not in the proton center but like a block away in another building, basically out of sight, out of mind.

Texas Protons does not have a linac on site, but in speaking with one of their former doctors, he wished they had. What happens if they have a patient whose randomized trial assigns them Xrays? They can't care for that patient anymore, unless they have a local partner site. Same thing if proton therapy is denied by insurance,they can't take care of that patient.

The question isn't so much which modality is better, because they both have strengths, but which patient is better for that modality.
 
IonsAreOurFuture said:
I have been to Procure in NJ. They do not have a linac, neither did Indiana University or the other 4 room behemoths. Provision in Knoxville did, not in the proton center but like a block away in another building, basically out of sight, out of mind.

Texas Protons does not have a linac on site, but in speaking with one of their former doctors, he wished they had. What happens if they have a patient whose randomized trial assigns them Xrays? They can't care for that patient anymore, unless they have a local partner site. Same thing if proton therapy is denied by insurance,they can't take care of that patient.

The question isn't so much which modality is better, because they both have strengths, but which patient is better for that modality.
Click to expand...
The (now closed) proton center at Indiana University was located about 50 miles south of their main academic center (Indianapolis to Bloomington). While it is true that the proton center wasn't in the same geographic location as the cancer center, IU certainly had (and retains!) the capacity to deliver photon treatments to its patients. It's not accurate to say that they "didn't have a linac".
 
communitydoc13 said:
My bias against protons is clear. I am a never user who has looked relatively deeply at the literature and discussed with multiple proton practitioners... and been basically appalled.

Protons will also function as a further consolidative measure. A 200 bed hospital that is a hub for cancer care in a rural county is not getting protons. Protons take lots of resources, including physics and therapy workforce, and will syphon these resources from smaller centers.

We are advocating for the dissemination of a high cost, high resource utilization intervention that is at best nominally better in certain niche indications.

Let's do the following thought experiment.

Imagine that the first widely disseminated modality for external beam radiation was in fact protons (or any other directly ionizing radiation). The physicists got it to work early, everybody was doing 2 field treatment anyway and the dose depth profile of ions was enough to justify their development.

But....there are intrinsic limitations to particle therapy and the physicist were still dealing with marked dosimetric uncertainties 5 decades later that prohibited meaningful high precision inverse planning, arc therapy or many beam angle therapy, fast patient throughput and affordability.

What would happen in the following scenario?

After a many decade head start, industry started applying advanced planning techniques to a more robust therapeutic radiation called photon therapy. They found that dosimetric calculations could be done very well, including accommodation of tissue density and rapid throughput of iterative planning. They found that you could administer XRT through roughly 360 degrees and modulate easily and dynamically with high density materials and still know where the dose dose was going in a patient.

The tech was also intrinsically cheaper; the infrastructure needed smaller; the treatments quicker.

What I think would happen?

Centers would clamor for the photon therapy immediately. There would be a bottom up movement to enroll in clinical trials demonstrating non-inferiority, which would have undoubtedly been demonstrated.

Radiation centers would become less centralized. Convenience for the patient would improve, with smaller treatment centers being able to offer therapy in rural areas.

By advocating for protons, we are not advocating for progress.
Click to expand...
Consider an alternative thought experiment, based on actual events in my life.

A friend once asked me in 2018 what I do for work. I told him that I shine Xrays through people's tumors to kill their cancers. As I was explaining it, it seemed more than a little crude to me, and I wondered if X-rays would be my ideal choice if I were starting from scratch nowadays?

Ideally, I'd want to kill only cancer cells and give minimal dose to normal cells. I would not a priori want to irradiate any tissues encountered before and after the tumor.

Alpha particles are great for that (very high LET, limited range) but hard to get into every cell in a tumor, and if given orally or by vein will irradiate lots of normal tissues too. Brachy is great, no entrance dose (unless you consider needle trauma "dose"), no exit dose, and very rapid fall off. Hard to implant every organ though, many are blocked by bones or have critical structures inside them (brainstem, vessels, airways, hollow viscus).

Xrays have low LET, high dose before the tumor, and continue beyond the tumor. Great for imaging with that exit dose - I don't think protons could have been used before the Xray era, in part because we can't image where the protons stopped in the body - no exit dose = no "port film" to see what we did. Great for imaging but the exit dose is wasted, and the pre-tumor dose is too.

Protons have higher LET, lower dose before a tumor, and nearly no exit dose after a tumor. We are just scratching the surface of what they can do (arcs, MRI guidance, RBE dose painting are coming) and have a lot more headroom for further refinement than the Xray techniques of the past 100 years.

The great thing is though, we get to use all of the above. It isn't either/or. That's a false dichotomy.
 
IonsAreOurFuture said:
It isn't either/or. That's a false dichotomy.
Click to expand...
The payment is a false dichotomy. Pay the same, see where the chips fall.

Something I learned relatively early (even before finishing residency), is that there are a ton of interventions that have demonstrated differential efficacy over standard of care (much more so than protons) but are not adopted because they either:

1. are a pain in the ass to do
2. carry some small risk of severe outcomes relative to standard of care
3. are not profitable or are prohibitively expensive.

Protons should be around. They can be around in a few places. They were around in a few places. We don't need ASTRO led regulatory capture to push community radonc out the door.

I also think they are probably worse in most clinical scenarios.

The aesthetics of protons be damned. Their RBE is so dependent on chemistry it's shocking. That proton-boron capture therapy exists, should make the clinician concerned, not excited about their treatment machine.
 
pikachu said:
The (now closed) proton center at Indiana University was located about 50 miles south of their main academic center (Indianapolis to Bloomington). While it is true that the proton center wasn't in the same geographic location as the cancer center, IU certainly had (and retains!) the capacity to deliver photon treatments to its patients. It's not accurate to say that they "didn't have a linac".
Click to expand...

Having something "in the network," but an hour away from one's regular practice, means that it basically doesn't exist, whether it's a linac, brachy, gamma knife or protons. The default is always to use what one has on hand, or as a friend of mine used to say, "you sell the cars you have on the lot."

I rarely get proton referrals from an hour away in Detroit, including for peds. Even when they are sent our way, many patients don't want to travel that far. Even less likely to go get protons if they're on concurrent chemo elsewhere, elderly, working full time (or both parents do), or afraid to drive in Flint.

Some of the many reasons why IU became defunct: 1. out of sight, out of mind; 2. inconvenient to get to for patients, MDs, and staff; 3. location, location, location. 4. Outdated equipment. 5. Outrageous overhead in staffing and maintenance.
 
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Why - in the current era with the evidence we have now - should tax payers pay a higher amount for protons ?

Yes, I have a bias, but I’m not closed minded.

My issue is that the proliferation was because 1) reimbursement was higher 2) Medicare spends like a drunken sailor.

If HiFU paid more than surgery, that would be a problem, even though it is theoretically better (well, in the eyes of some urologists and the marketing people).

I want the market to decide, until the evidence does. Otherwise, this is a rigged game. And it’s not Flint. Flint is not the problem. It’s the massive academic centers installing multiple rooms and taking as a have of payment differential and associated Halo Effect
 
RealSimulD said:
Why - in the current era with the evidence we have now - should tax payers pay a higher amount for protons ?

Yes, I have a bias, but I’m not closed minded.

My issue is that the proliferation was because 1) reimbursement was higher 2) Medicare spends like a drunken sailor.

If HiFU paid more than surgery, that would be a problem, even though it is theoretically better (well, in the eyes of some urologists and the marketing people).

I want the market to decide, until the evidence does. Otherwise, this is a rigged game. And it’s not Flint. Flint is not the problem. It’s the massive academic centers installing multiple rooms and taking as a have of payment differential and associated Halo Effect
Click to expand...
That is a really great question, one that my wife often asks me, or a variant of it - "Are protons really worth the added cost?" Or as I think of it, are protons "better enough"?

The answer is a long one..one that I've been pondering for over 5 years.

I suppose it depends on what we value. If we only value local control, which is a function of dose to tumor, the answer is no, protons are not more valuable. 3D, or even 2D radiation, can give 70 or 80 Gy to any tumor.

However, if value is a function of reducing side effects to a socially acceptable level, then I think the answer is yes, or at least, in certain cases - yes, protons are "better enough."

The definition of socially acceptable varies from nation to nation and over time. The side effects that patients endured in the cobalt and pre-cobalt eras makes me wonder how we even survived as a field, and yet it was the best thing we had at the time, at least until Linacs got better and now mass produced.

The Netherlands [emoji1179] has been rationing their proton access in its 2 centers according to whether or not a patient's anatomy is predicted by a model to benefit from protons. Eg, in head and neck, will OAR constraints be unmet by IMRT, or "better enough" by protons? If so, then they will cover it. The computer model improves over time with more cases.

I apply a similar mental model in my clinic every day. Some patients want protons, no matter what, even if I don't know they will benefit. Others don't want to travel for protons, even I know it might save them severe toxicity. Most often I tell them that I won't know for sure if they'll need protons until we simulate them and make a comparison plan.

Typically now I can predict by exam and imaging who will be "better enough," ie, not able to meet breast/heart/LAD constraints with DIBH, or H&N constraints with IMRT/VMAT. However, it's taken me 5 years and a mid-career fellowship to get there. AI and autoplanning will hopefully pick it up more quickly than that, because there is a shortage of experienced people at all levels in the proton world, and I don't believe that a weekend course is good enough for a human to confidently make the switch at this point.

It's important to realize that in terms of patients treated, protons are only at 250k patients globally. That may sound like a lot, but it isn't a lot per doctor or center. IMRT probably got to that number in 30, because the number of annual Xray patients is about 99 times higher than protons.

We are still in the early days and the steep part of the learning curve, like when IMRT was burning people's lips unexpectedly and SBRT was causing rib fractures, chestwall necrosis, and a no-fly zone lung had not been identified. Some people I met didnt want to learn 3D contouring skills or prescribe 20 Gy per fraction, and never picked it up. IMRT even ended up on the front page of the New York times for accidentally killing a guy. I don't think any of us gave up IMRT over that, but it was a learning moment for our field and reinforced the need for QA before beaming on.

New indications will continue to emerge for particles, and side effects will go down, just as they have for IMRT and SBRT in the last 15 years. There are still about 100 metro areas in the US with >500k population, i.e. larger and economically healthier than Flint, with higher expectations for their healthcare, for whom protons will be "better enough."
 
IonsAreOurFuture said:
Texas Protons does not have a linac on site, but in speaking with one of their former doctors, he wished they had. What happens if they have a patient whose randomized trial assigns them Xrays? They can't care for that patient anymore, unless they have a local partner site. Same thing if proton therapy is denied by insurance,they can't take care of that patient.
Click to expand...
I know not many will believe me on this. And will swear up and down with their dying breath I am wrong. But…

There is not an insurance company in existence that would “care” or “mind” if a proton center treated with protons and got pre-auth for IMRT and billed IMRT codes for doing proton treatments. Much less would the insurance company sue. MUCH less would this approach be illegal or criminal.

How do I know? I just know! Trust me. Once I knew it, I could hardly believe it.
 
TheWallnerus said:
I know not many will believe me on this. And will swear up and down with their dying breath I am wrong. But…

There is not an insurance company in existence that would “care” or “mind” if a proton center treated with protons and got pre-auth for IMRT and billed IMRT codes for doing proton treatments. Much less would the insurance company sue. MUCH less would this approach be illegal or criminal.

How do I know? I just know! Trust me. Once I knew it, I could hardly believe it.
Click to expand...
Medicare/CMS would care.. Private payors won't.
 
TheWallnerus said:
I know not many will believe me on this. And will swear up and down with their dying breath I am wrong. But…

There is not an insurance company in existence that would “care” or “mind” if a proton center treated with protons and got pre-auth for IMRT and billed IMRT codes for doing proton treatments. Much less would the insurance company sue. MUCH less would this approach be illegal or criminal.

How do I know? I just know! Trust me. Once I knew it, I could hardly believe it.
Click to expand...
The disclaimer here is that I'm with @TheWallnerus on this...but am also unable to provide evidence right now. Sorry friends.

People think that the relationship between medicine and insurance is much more robust than it actually is. Especially in RadOnc.

Private insurance is much closer to a franchise model than a monolith. We often talk (and publish) as if BCBS is the same for all of us.

It's actually like McDonalds. Yeah, there's a centralized office. They run on the same systems, use the same words and products.

But the McDonalds you go to on Broadway is not the same as the McDonalds you go to on Park Ave. The BCBS plan a patient in Maine has is not the same BCBS plan a patient in Idaho has. So when we argue/debate each other about our insurance issues - both "sides" can be right. Maybe the ice cream machine on Broadway really does work all the time, and the ice cream machine on Park Ave is always broken.

Folks talk about "underbilling" with a tone of legality. Insurance is not medicine. Delivering radiotherapy and billing at rates for a cheaper version of radiotherapy is not against the law. No private company is going to get mad about it. You're saving the company (and the patient) a ton of money and the company had to do zero work to make it happen. It's their dream. They wish we did this all the time.

CMS can be a different tale. The government is weird. Yes, by the literal definition - billing the government for a cheaper course of radiotherapy is "fraud" - you're telling them you're doing one thing but actually doing another.

It's fraud in same direction, though. You're saving the government and patient money.

Playing this out - what could happen if you bill Medicare for IMRT but deliver protons? First, it could be discovered during a RAC audit. Despite the perception...RAC audits have changed a lot. They're actually relatively new - showing up in 2005. But it was regional. They only came out nationally in 2010. They exploded for a few years.

Technically they got paid on contingency, and were incentivized to recover dollars. Popping clinics for underpayments is NOT recovering dollars, but underpayments were still in their purview. Regardless...CMS decided that things had gotten insane and reformed them in 2018. When was the last time you heard about a clinic doing a RAC audit? For me, it was a non-RadOnc practice and the year was...2018. I personally don't know of any in the last 5 years.

We also have everyone's favorite: qui tam or "whistleblower" risk. Most people don't know how this happens either - we talk like it's "you tell the government something is happening, the government investigates and prosecutes".

The government isn't involved at all in the beginning. You have to go to private law firms with your case. The private firms have to choose to take the case. Then, the private firm has to convince the government to take the case. The government can (and often does) choose to not pursue a whistleblower complaint. In that instance, the whistleblower (relator) and private firm can still proceed - but without the government's assistance (as in - pay for the entire thing). You ever heard of a Medicare whistleblower case happening without the government's involvement?

1685195722615.png


But, at the end of the day - the "truth" often doesn't matter. The billing department is technically correct labeling billing protons as IMRT as "fraud" - saying you're doing one thing but doing something else - and that's the end of the story.

AMERICA!
 
There will never be an under billing fraud case unless there is a discrepancy that leads to enrichment of the physician. And in this case, if they did the “right” thing they would make the same or more. The Feds are dumb, but not dumb enough to spend money to give money to doctors.

Bc that’s the end outcome.
 
IonsAreOurFuture said:
That is a really great question, one that my wife often asks me, or a variant of it - "Are protons really worth the added cost?" Or as I think of it, are protons "better enough"?

The answer is a long one..one that I've been pondering for over 5 years.

I suppose it depends on what we value. If we only value local control, which is a function of dose to tumor, the answer is no, protons are not more valuable. 3D, or even 2D radiation, can give 70 or 80 Gy to any tumor.

However, if value is a function of reducing side effects to a socially acceptable level, then I think the answer is yes, or at least, in certain cases - yes, protons are "better enough."

The definition of socially acceptable varies from nation to nation and over time. The side effects that patients endured in the cobalt and pre-cobalt eras makes me wonder how we even survived as a field, and yet it was the best thing we had at the time, at least until Linacs got better and now mass produced.

The Netherlands [emoji1179] has been rationing their proton access in its 2 centers according to whether or not a patient's anatomy is predicted by a model to benefit from protons. Eg, in head and neck, will OAR constraints be unmet by IMRT, or "better enough" by protons? If so, then they will cover it. The computer model improves over time with more cases.

I apply a similar mental model in my clinic every day. Some patients want protons, no matter what, even if I don't know they will benefit. Others don't want to travel for protons, even I know it might save them severe toxicity. Most often I tell them that I won't know for sure if they'll need protons until we simulate them and make a comparison plan.

Typically now I can predict by exam and imaging who will be "better enough," ie, not able to meet breast/heart/LAD constraints with DIBH, or H&N constraints with IMRT/VMAT. However, it's taken me 5 years and a mid-career fellowship to get there. AI and autoplanning will hopefully pick it up more quickly than that, because there is a shortage of experienced people at all levels in the proton world, and I don't believe that a weekend course is good enough for a human to confidently make the switch at this point.

It's important to realize that in terms of patients treated, protons are only at 250k patients globally. That may sound like a lot, but it isn't a lot per doctor or center. IMRT probably got to that number in 30, because the number of annual Xray patients is about 99 times higher than protons.

We are still in the early days and the steep part of the learning curve, like when IMRT was burning people's lips unexpectedly and SBRT was causing rib fractures, chestwall necrosis, and a no-fly zone lung had not been identified. Some people I met didnt want to learn 3D contouring skills or prescribe 20 Gy per fraction, and never picked it up. IMRT even ended up on the front page of the New York times for accidentally killing a guy. I don't think any of us gave up IMRT over that, but it was a learning moment for our field and reinforced the need for QA before beaming on.

New indications will continue to emerge for particles, and side effects will go down, just as they have for IMRT and SBRT in the last 15 years. There are still about 100 metro areas in the US with >500k population, i.e. larger and economically healthier than Flint, with higher expectations for their healthcare, for whom protons will be "better enough."
Click to expand...
I agree theoretically better. But all examples you’ve said are not evidence based (or strong evidence).

The NYTimes case wasn’t because of IMRT. The leaves didn’t change. This could happen with 3D. Had zero to do with technique.
 
elementaryschooleconomics said:
The disclaimer here is that I'm with @TheWallnerus on this...but am also unable to provide evidence right now. Sorry friends.

People think that the relationship between medicine and insurance is much more robust than it actually is. Especially in RadOnc.

Private insurance is much closer to a franchise model than a monolith. We often talk (and publish) as if BCBS is the same for all of us.

It's actually like McDonalds. Yeah, there's a centralized office. They run on the same systems, use the same words and products.

But the McDonalds you go to on Broadway is not the same as the McDonalds you go to on Park Ave. The BCBS plan a patient in Maine has is not the same BCBS plan a patient in Idaho has. So when we argue/debate each other about our insurance issues - both "sides" can be right. Maybe the ice cream machine on Broadway really does work all the time, and the ice cream machine on Park Ave is always broken.

Folks talk about "underbilling" with a tone of legality. Insurance is not medicine. Delivering radiotherapy and billing at rates for a cheaper version of radiotherapy is not against the law. No private company is going to get mad about it. You're saving the company (and the patient) a ton of money and the company had to do zero work to make it happen. It's their dream. They wish we did this all the time.

CMS can be a different tale. The government is weird. Yes, by the literal definition - billing the government for a cheaper course of radiotherapy is "fraud" - you're telling them you're doing one thing but actually doing another.

It's fraud in same direction, though. You're saving the government and patient money.

Playing this out - what could happen if you bill Medicare for IMRT but deliver protons? First, it could be discovered during a RAC audit. Despite the perception...RAC audits have changed a lot. They're actually relatively new - showing up in 2005. But it was regional. They only came out nationally in 2010. They exploded for a few years.

Technically they got paid on contingency, and were incentivized to recover dollars. Popping clinics for underpayments is NOT recovering dollars, but underpayments were still in their purview. Regardless...CMS decided that things had gotten insane and reformed them in 2018. When was the last time you heard about a clinic doing a RAC audit? For me, it was a non-RadOnc practice and the year was...2018. I personally don't know of any in the last 5 years.

We also have everyone's favorite: qui tam or "whistleblower" risk. Most people don't know how this happens either - we talk like it's "you tell the government something is happening, the government investigates and prosecutes".

The government isn't involved at all in the beginning. You have to go to private law firms with your case. The private firms have to choose to take the case. Then, the private firm has to convince the government to take the case. The government can (and often does) choose to not pursue a whistleblower complaint. In that instance, the whistleblower (relator) and private firm can still proceed - but without the government's assistance (as in - pay for the entire thing). You ever heard of a Medicare whistleblower case happening without the government's involvement?

View attachment 372265

But, at the end of the day - the "truth" often doesn't matter. The billing department is technically correct labeling billing protons as IMRT as "fraud" - saying you're doing one thing but doing something else - and that's the end of the story.

AMERICA!
Click to expand...
Not only is insurance like a "franchise," but they offer many different products. Most Americans receive insurance through their employer who pays for the actual medical expenses while the insurance acts as a middleman/claims manager.
 
sirspamalot said:
Medicare/CMS would care.. Private payors won't.
Click to expand...
This is a red herring retort! There’s no prior auth with Medicare or policy criteria to meet. Except for LCDs. But for example there are no LCDs for IGRT, for special treatment procedure, or many other things. And even then, one can look at the LCDs for protons and see the LCD says it is ok to bill SBRT for protons. Things of this nature.
 
TheWallnerus said:
This is a red herring retort! There’s no prior auth with Medicare or policy criteria to meet. Except for LCDs. But for example there are no LCDs for IGRT, for special treatment procedure, or many other things. And even then, one can look at the LCDs for protons and see the LCD says it is ok to bill SBRT for protons. Things of this nature.
Click to expand...
Crab rangoons
 
Not following. But, what I am saying is: Medicare/CMS has the right to pursue underbilling as it is also considered fraud. Would they? Unlikely. But who knows: when its your turn to take the lash... it ain't good.
 
This is pure conjecture- but I would only think that underbilling would be an issue if it undercuts your competition and they complain. But unlike buying cars or furniture, patients do not shop around for their cancer care. Sure they'll get 2nd opinions, but they are (for the most part) not trying to get the best deal. And with out of pocket costs not directly correlating costs billed to insurers, and what insurers actually pay, along with out of pocket costs tied into in- vs out- of network care, things get so muddy that patients probably are not able to make informed decisions. Nor do patients understand all of this. Are patients really going to know or understand that they might get free IGRT for their spine metastases at one practice but not another ? If a case of underbilling ever went so far as a court room, I'd be shocked.
 
radiaterMike said:
This is pure conjecture- but I would only think that underbilling would be an issue if it undercuts your competition and they complain. But unlike buying cars or furniture, patients do not shop around for their cancer care. Sure they'll get 2nd opinions, but they are (for the most part) not trying to get the best deal. And with out of pocket costs not directly correlating costs billed to insurers, and what insurers actually pay, along with out of pocket costs tied into in- vs out- of network care, things get so muddy that patients probably are not able to make informed decisions. Nor do patients understand all of this. Are patients really going to know or understand that they might get free IGRT for their spine metastases at one practice but not another ? If a case of underbilling ever went so far as a court room, I'd be shocked.
Click to expand...
It wouldn’t even get to the point of being examined. It specifically says the actions need to enrich the physician. It’s indirect to say that an insurance denial resulting in lower reimbursement caused increase in revenue. Chasing our tails.
 
It enriches the physician only if it undercuts competition. But patients do not 'shop' their cancer care so it really does not apply.
 
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