RTOG question

[Gfunk6]

For those of you running RTOG trials at your centers, do you know how reimbursement works for experimental treatments?

For instance, if you put a patient on an IMRT Phase I/II trial when the standard of care is 3DCRT, do you get IMRT reimbursement? Or do you get 3D reimbursement?

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[TarHeelRadOnc]

For those of you running RTOG trials at your centers, do you know how reimbursement works for experimental treatments?

For instance, if you put a patient on an IMRT Phase I/II trial when the standard of care is 3DCRT, do you get IMRT reimbursement? Or do you get 3D reimbursement?

You get IMRT reimbursement for IMRT, and 3D reimbursement for 3D. This is independent of whether patient is treated on trial. For some trials, reimbursement has been denied by private insurers (SBRT for spine on 0631 and IMRT for rectal cancer are two notable examples). In these cases, your options are to either write off the "experimental" treatment (which you would need to clear with hospital if you are not at a freestanding facility) or to not offer treatment on trial (sucks either way). One important point: You cannot bill an IMRT plan as 3D! This is considered medicare/insurance fraud, which is ridiculous seeing as you are billing for a considerably less expensive code! The RTOG does reimburse a fixed rate per patient for patients treated on trial. This amount varies for each trial, and can partially offset insurance coverage issues.

 

[Gfunk6]

That was extremely helpful, thank you!

 

[deleted4401]

It's funny how underbilling is as severe a crime as overbilling.

Curious - say you were an average professional only practice, 20-25 patients on treatment, and you did everything 3D, no IMRT. Still did everything else - IGRT, etc. What do you think you'd make?