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alwaysbeIMRTing said:
They will do it again. The obsession from a minority of academic rad oncs over eliminating the correlation between practice revenue and fractions, physician ownership of LINACs, and general supervision will never die and every failure to control the rest of us just pisses them off and emboldens them more. Yeah. Medicare cuts suck. We all agree on that. But this was a lame lie using that to try and sell the above bigger picture to uninformed community docs. The single biggest thing ASTRO can do right now if it cares about the rest of us is protect the payments from 77014 ensuring that the new PC of the treatment code accounting for cbct review is not less on the fee schedule than it was for 77014 (or worst case, zero). Fixed case rates in some settings only are not the way to do that.
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Speaking of which, I know this came up in a thread a few months ago and Simul had a good blog post about it, but does anyone know when/where the new fee schedule is released with the new code(s) for image guidance and wRVU amounts?
 
HolySmokes said:
Speaking of which, I know this came up in a thread a few months ago and Simul had a good blog post about it, but does anyone know when/where the new fee schedule is released with the new code(s) for image guidance and wRVU amounts?
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I don't think the wRVU or reimbursement for the code has been announced yet but would like to see it as well if someone knows.

From people I talk to, it sounds like there *may* be bundling of things like CBCT, surface guidance, orthogal X-rays...all of which had their own codes into one catch-all image-guidance code.....which will *you guessed it* pay less than a CBCT. How much less TBD.
 
alwaysbeIMRTing said:
I would also love to know the rationale behind and just how the AMA came to suddenly decide to "delete" 77014. How exactly did this happen?
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YES!

I presume you meant CMS....but I don't know how they decide to just cut and bundle. Very opaque process but surely if ASTRO or our "leaders" are involved in shaping this there is much to be concerned about.
 
The AMA somehow has a monopoly in establishing CPT(®) codes. It's a total racket.

Accepted revision of codes 77402, 77407, 77412 77412 to consolidate and more clearly specify services provided for radiation treatment delivery; deletion of codes 77014, 77385, 77386; revision, deletion, and addition of introductory guidelines to better define, explain, and differentiate the levels for radiation treatment delivery services; addition of definitions within the guidelines; and revision of the existing Radiation Management and Treatment Table in the Radiology section to accommodate the new codes
 
BobbyHeenan said:
YES!

I presume you meant CMS....but I don't know how they decide to just cut and bundle. Very opaque process but surely if ASTRO or our "leaders" are involved in shaping this there is much to be concerned about.
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Can we have a separate thread on what people know about how this will go down. It's already bundled in free-standing right? We're just gonna use a different code with about a 50-60% cut? Like 77014 will become g6002, a different new code, or just nothing?
 
Ray D. Ayshun said:
Can we have a separate thread on what people know about how this will go down. It's already bundled in free-standing right? We're just gonna use a different code with about a 50-60% cut? Like 77014 will become g6002, a different new code, or just nothing?
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That may be helpful.

I only know about hospital based pro fee billing...not sure about free standing.

We've had some chatter here but I can't believe more people on twitter or in publications aren't screaming to high heavens regarding this change...it is a HUGE chunk of our revenue.
 
alwaysbeIMRTing said:
The AMA somehow has a monopoly in establishing CPT(®) codes. It's a total racket.

Accepted revision of codes 77402, 77407, 77412 77412 to consolidate and more clearly specify services provided for radiation treatment delivery; deletion of codes 77014, 77385, 77386; revision, deletion, and addition of introductory guidelines to better define, explain, and differentiate the levels for radiation treatment delivery services; addition of definitions within the guidelines; and revision of the existing Radiation Management and Treatment Table in the Radiology section to accommodate the new codes
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I don't really understand how this is valid. 5 of the 6 codes are tech only, while 77014 is prof only.
 
alwaysbeIMRTing said:
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alwaysbeIMRTing said:
It's a mystery. Why would the AMA decide to get rid of this code? How did this come up? How do we bill for CBCT review now? They have a monopoly in setting codes.
I suspect ASTRO ROCR shenanigans.
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But including it in that sentence is basically saying we're eliminating imaging review in order to replace it with treatment delivery. It's more like a typo that probably harkens back to the fact that nobody ever decided to clarify the confusion about billing 77014 at sim vs treatment.
 
Ray D. Ayshun said:
But including it in that sentence is basically saying we're eliminating imaging review in order to replace it with treatment delivery. It's more like a typo that probably harkens back to the fact that nobody ever decided to clarify the confusion about billing 77014 at sim vs treatment.
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The description of the code has never made sense for how it is billed post-2014 CT guidance for placement of radiation fields. That's not what I'm doing at the end of treatment every day. 77014 -26 pays $43. Just increase 77427 by $43 x5 since what we're really doing is management. What's the plan? Somebody knows something.
 
alwaysbeIMRTing said:
The description of the code has never made sense for how it is billed post-2014 CT guidance for placement of radiation fields. That's not what I'm doing at the end of treatment every day. 77014 -26 pays $43. Just increase 77427 by $43 x5 since what we're really doing is management. What's the plan? Somebody knows something.
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So are they just deleting codes now to force support for case rates?
 
TheWallnerus said:
Translation: hands off my protons, Medicare
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McBride isn't pro proton zealot by any stretch of the imagination.

also are people going to act like medicare requiring prior auth for rad onc would be a favorable thing for any of us? we all love medicare patients and the freedom we have to treat how we best see fit right now. Having an extra hurdle would not be good to me. Your mileage may vary.
 
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drowsy12 said:
McBride isn't pro proton zealot by any stretch of the imagination.

also are people going to act like medicare requiring prior auth for rad onc would be a favorable thing for any of us? we all love medicare patients and the freedom we have to treat how we best see fit right now. Having an extra hurdle would not be good to me. Your mileage may vary.
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It would barely change anything for me. United and Aetna have already convinced most of my patients they're supplementing their Medicare and not replacing it. Medicare proper doing prior auth would only decrease job tolerability incrementally. It certainly won't be the straw.
 
drowsy12 said:
also are people going to act like medicare requiring prior auth
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The scope of the ROCR bashing is too broad IMO. The wisdom of the initiative (obviously looking like a failure now) is in relation to the impending alternative, which is presently unknown. However, I believe we are looking at radically different payment models in the near future (which will cut nearly all of our payments).

The present congressional bill will have an immediate impact on Medicaid and likely a very substantial impact on Medicare in the relatively near future. We will be caught up with everyone else. If your hospital is hemorrhaging, there is only so much leverage that one revenue generating department has. Let's not pretend that our relative profitability is a function of present day rational payment policy.

Case based? I love the idea. "Incentivized to do less"?...I don't think of it that way. I wouldn't do much less than I do now with case based payment. I'm neither trying to maximize revenue nor RVUs. I have yet to see a department that doesn't do lots (as in a huge amount) of things that are "probably not necessary".

It was the exceptions, pure and simple, that alienated me regarding ROCR. Protons of course having yet to demonstrate much beyond boondoggle. Remarkably little positive proton data coming out presently (the spinning of PARTIQoL being egregious).

The exceptions are reminiscent of elitist political behavior across the board, which is about donors and forming networks of elites to create policy that preserves and enhances the advantages of the wealthy. They would have gotten my support if they had gotten rid of them.
 
Ray D. Ayshun said:
It would barely change anything for me. United and Aetna have already convinced most of my patients they're supplementing their Medicare and not replacing it. Medicare proper doing prior auth would only decrease job tolerability incrementally. It certainly won't be the straw.
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I have a good amount of straight Medicare patients.
 
Ray D. Ayshun said:
As do I. Even in patients where prior auth is required, though, it's really only annoying once every 2 or 3 months.
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I've got to fill out 3-4 sheets a week with contentious approval probably 2x a month. These numbers will probably double if Medicare starts acting like MA. Also, timeliness of scheduling impacted routinely.
 
communitydoc13 said:
I've got to fill out 3-4 sheets a week with contentious approval probably 2x a month. These numbers will probably double if Medicare starts acting like MA. Also, timeliness of scheduling impacted routinely.
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Do you wait for approval even for things that are clear cut? I guess I'm just lucky. It's not like I don't hate our medical system, I'm just not seeing a massive preauth burden.
 
Ray D. Ayshun said:
Do you wait for approval even for things that are clear cut? I guess I'm just lucky. It's not like I don't hate our medical system, I'm just not seeing a massive preauth burden.
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It's not the worst. On occasion scheduling does become an issue, and the burden of this falls on others in my clinic, although it makes more work for everyone.

But the spector of pre-auth does probably change the way I practice. It is very nice to just SBRT that single spine met in a pCa patient while treating the primary.
 
In the end, ROCR was neither big nor beautiful. Puny and stinky isn't going to cut it.

With regards to prior authorization for medicare, the problem is that waste and fraud exists. I pointed out the ENT that had collected (not charged) over 1M in a single year from medicare for G6001 for ultrasound image guidance of every fraction with a superficial RT machine. This is outright fraud and PA would have shot this down. As much as everyone here hates PA, I dare anyone to defend that.

And then there are protons for medicare prostate patients. Fraud, eh... Private practice proton centers must currently be freaking out.

If CMS allows protons for routine prostate in the future but shoots down 45 fraction prostate VMAT and more than 5 fraction breast VMAT, we have a problem.

Am I arguing for evicore gatekeeping straight medicare patients? Of course not. But we here, in our income brackets, are all statistically shouldering the vast majority of the tax burden in this country and should have a problem with our 37% haircut being funneled to fraudsters.
 
alwaysbeIMRTing said:
being funneled to fraudsters
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agree that fraud exists.

But the simplest way to alleviate the above issues is through case based payment.

IGRT for superficial skin? Do it if you think its of value, but I'm paying you the same as the radonc doing a clinical e set-up.

44 fractions IMRT for pCa....sure. Sometimes the guy has bad LUTS coming in. Still getting paid same as 28 fractions or 20.

Protons...pays the same. Use it only when it provides value to the patient not your wallet.

Case based preserves our discretionary power as physicians.
 
Imagine being a dentist and getting paid a flat rate per diseased tooth by the government. Well, sir I just don't think an implant is going to be possible there. Extractions for everyone. The incentivization of simpler medical care is self-evident unless you are in denial about human nature.

I remember when I went to medical school, I nervously approached my intimidating boss at the time (A very conservative Scotsman, who was clearly no fan of the NHS) who deadpan responded to me with "so you're quitting my company to go work for the government?" It took me a long time to understand what he meant, and I get it now.

Professionals should value their time and should not accept equal reimbursement for disparate amounts of work. My lawyer or CPA certainly wouldn't. I don't expect the same fee for tax prep next year if I open a real estate business, do locums at 15 different locations in multiple states, buy shares in an oil well in Canada, and obtain a fleet of luxury rental cars. There has to be a solution somewhere between case rates and letting CMS continually cut reimbursements while auditing basically nothing of what they pay out.
 
alwaysbeIMRTing said:
Imagine being a dentist and getting paid a flat rate per diseased tooth by the government. Well, sir I just don't think an implant is going to be possible there. Extractions for everyone. The incentivization of simpler medical care is self-evident unless you are in denial about human nature.

I remember when I went to medical school, I nervously approached my intimidating boss at the time (A very conservative Scotsman, who was clearly no fan of the NHS) who deadpan responded to me with "so you're quitting my company to go work for the government?" It took me a long time to understand what he meant, and I get it now.

Professionals should value their time and should not accept equal reimbursement for disparate amounts of work. My lawyer or CPA certainly wouldn't. I don't expect the same fee for tax prep next year if I open a real estate business, do locums at 15 different locations in multiple states, buy shares in an oil well in Canada, and obtain a fleet of luxury rental cars. There has to be a solution somewhere between case rates and letting CMS continually cut reimbursements while auditing basically nothing of what they pay out.
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depending on where you work...the government is paying you...for me...probably about 70-75% of revenue that factors into calculations for my reimbursement is from the government.

Doctors and dentists are different...dentists are richer

Rich people can pay out of pocket for protons

Regarding case based payment...it's about the data used for calculating rates. In principle (I don't know if true) I believe an initiative such as ROCR should have assumed "reasonableness" about our aggregate practice patterns for establishing generalized payment schedules. This means that the doctor who is maximizing fractions pays a cost, while typical docs do about the same (better than sequential Medicare cuts actually). The concept was not bogus IMO, of course the implementation was.
 
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communitydoc13 said:
I've got to fill out 3-4 sheets a week with contentious approval probably 2x a month. These numbers will probably double if Medicare starts acting like MA. Also, timeliness of scheduling impacted routinely.
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We trained our prior auth people to fill out these sheets themselves because we dictate our treatment plan and stage on their consult note (ie all the relevant info is in their consult). This improved our work flow substantially.

?Maybe this is an option for you?
 
BobbyHeenan said:
We trained our prior auth people to fill out these sheets themselves because we dictate our treatment plan and stage on their consult note (ie all the relevant info is in their consult). This improved our work flow substantially.

?Maybe this is an option for you?
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Agree this is ideal and should be doable.

Unfortunately, my hospital has hired a third party (huge mistake IMO) for front office staffing. This means remote management of this team, lack of labor continuity on this end and very little accountability to us. Trying to rectify presently. I routinely get an evicore form for pCa when clear it should be for a bone met per consult note.

I don't want to make PA out to be the ultimate bogeyman, but it does add steps fairly often. I have a fair number of patients where final treatment decisions from a technical standpoint are only made at time of sim (APBI vs WBRT, IMRT vs 3D for RNI, dose fractionation regarding early stage NSCLCa contingent on setup/breathing/OAR dose). I would prefer it not exist.

What has been discussed for ages...and no AI necessary, although big data tools are helpful...is that one can apply statistical tools to reduce admin burden and allow docs/hospitals to have maximum discretion with patient care...while providing for audits or even incentives to assess and punish outliers regarding billing or practice patterns. This facilitates care in exceptional cases and ensures reasonableness with marked reduction in administrative burden (on part of both payor (usually gvt or proxy) and provider.

Private payors (including advantage plans) may not incentivized to do this (frankly a threat to their whole industry....certainly from a workforce standpoint). I am aware of UMich health system floating a plan like this with their major private payor decades ago...with no success.

Edit: I would prefer the above to AI auditing every case.
 
communitydoc13 said:
Agree this is ideal and should be doable.

Unfortunately, my hospital has hired a third party (huge mistake IMO) for front office staffing. This means remote management of this team, lack of labor continuity on this end and very little accountability to us. Trying to rectify presently. I routinely get an evicore form for pCa when clear it should be for a bone met per consult note.

I don't want to make PA out to be the ultimate bogeyman, but it does add steps fairly often. I have a fair number of patients where final treatment decisions from a technical standpoint are only made at time of sim (APBI vs WBRT, IMRT vs 3D for RNI, dose fractionation regarding early stage NSCLCa contingent on setup/breathing/OAR dose). I would prefer it not exist.

What has been discussed for ages...and no AI necessary, although big data tools are helpful...is that one can apply statistical tools to reduce admin burden and allow docs/hospitals to have maximum discretion with patient care...while providing for audits or even incentives to assess and punish outliers regarding billing or practice patterns. This facilitates care in exceptional cases and ensures reasonableness with marked reduction in administrative burden (on part of both payor (usually gvt or proxy) and provider.

Private payors (including advantage plans) may not incentivized to do this (frankly a threat to their whole industry....certainly from a workforce standpoint). I am aware of UMich health system floating a plan like this with their major private payor decades ago...with no success.

Edit: I would prefer the above to AI auditing every case.
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I guess this is the difference. I have the luxury of working with a competent biller.
 
communitydoc13 said:
Agree this is ideal and should be doable.

Unfortunately, my hospital has hired a third party (huge mistake IMO) for front office staffing. This means remote management of this team, lack of labor continuity on this end and very little accountability to us. Trying to rectify presently. I routinely get an evicore form for pCa when clear it should be for a bone met per consult note.

I don't want to make PA out to be the ultimate bogeyman, but it does add steps fairly often. I have a fair number of patients where final treatment decisions from a technical standpoint are only made at time of sim (APBI vs WBRT, IMRT vs 3D for RNI, dose fractionation regarding early stage NSCLCa contingent on setup/breathing/OAR dose). I would prefer it not exist.

What has been discussed for ages...and no AI necessary, although big data tools are helpful...is that one can apply statistical tools to reduce admin burden and allow docs/hospitals to have maximum discretion with patient care...while providing for audits or even incentives to assess and punish outliers regarding billing or practice patterns. This facilitates care in exceptional cases and ensures reasonableness with marked reduction in administrative burden (on part of both payor (usually gvt or proxy) and provider.

Private payors (including advantage plans) may not incentivized to do this (frankly a threat to their whole industry....certainly from a workforce standpoint). I am aware of UMich health system floating a plan like this with their major private payor decades ago...with no success.

Edit: I would prefer the above to AI auditing every case.
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3rd party for prior auth or billing is a disaster in my experience.

It can be a pain in the rear but getting that in house makes a world of difference. Especially if YOU (rather than some person in a cubicle) are seen as the "boss" of that aspects of things...rather than an off site person or an admin.
 
BobbyHeenan said:
3rd party for prior auth or billing is a disaster in my experience.

It can be a pain in the rear but getting that in house makes a world of difference. Especially if YOU (rather than some person in a cubicle) are seen as the "boss" of that aspects of things...rather than an off site person or an admin.
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Absolute disaster. We do our pro fees billing as a practice no problem, and my department bills technical well. This was a hospital wide decision regarding scheduling/preauth etc (and a poor one) likely based on poor performance in other outpatient departments. The departments who were functioning well with autonomy have really suffered.
 
Prior auth, despite the corporate description of it, is about saving money. That's it. Nothing more. It has nothing to do with inappropriate care. They just want to drag you down with faceless bureaucracy until you throw in the towel. As such, prior auth will "evolve" past your ability to document accurately.

Instead of saying "what you're doing is not the standard of care" it will be "we didn't get your consult note" (even after you sent it to them x5 on their own electronic portal).
 
communitydoc13 said:
It was the exceptions, pure and simple, that alienated me regarding ROCR. Protons of course having yet to demonstrate much beyond boondoggle.
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Do the ongoing annual Medicare reimbursement cuts affect protons and PPSE universities? If so let’s go with the status quo instead of a carve out for protons. Let elite academics burn with the rest of us.
 
Case based is likely better for us in the community as long as there are no carve outs for protons, MRL, adaptive, etc.

With all those carve outs, it just incentivizes crap 💩 treatments in the community and runaway spending for unproven unknown outcomes in academic centers.
 
yesmaster said:
Do the ongoing annual Medicare reimbursement cuts affect protons and PPSE universities? If so let’s go with the status quo instead of a carve out for protons. Let elite academics burn with the rest of us.
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Ummm no?

May be a weird take but I care more about myself and my practice than sticking it to someone else
 
I have had docs from big private groups tell me ROCR was the way to go.
Does anyone have good information on what groups would actually benefit versus who wouldn't? Are smaller docs getting screwed by it?
 
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