Presented by:
Denise A. Merlino, MBA, CNMT, CPC, FSNMTS
Reimbursement Update – Efforts for Changes to Medicare
Hospital Payment Policy (HOPPS)
2-29-2016
Presenter & Disclosures
Denise Merlino, MBA, CNMT, FSNMMI, CPC
President, Merlino Healthcare Consulting Corp.
Gloucester, MA
2
Consultant to: SNMMI & ACNM & ASNC
Bracco & UPPI & Pharmalucence
American Thoracic Society (ATS)
American College of Chest Physicians (CHEST)
American Geriatrics Society (AGS)
American Society for Clinical Oncology (ASCO)
Renal Physicians Association (RPA)
Topics – Medicare
1. Current Status of Medicare Payment Policy
• Hospital Outpatient (aka HOPPS)
• Charge Masters - Slow Adoption - Charge Compression
2. Initiative Addressing Coding & Billing Errors
• Rp to Procedure Code Edits
• A prospective, proactive solution for inappropriate payments
3. Alternative APC Group Configurations
• Consolidation of Procedure APC Groups
• Creation of diagnostic radiopharmaceutical APC Groups
• Use of voluntarily supplied Average Sales Price for
Diagnostic Radiopharmaceuticals
3
1. CURRENT STATUS
MEDICARE PAYMENT POLICY
Hospital Outpatient Payment System (HOPPS)
4
5
Hospital
Inpatient IPPS/DRG
On Campus-
Hospital
Outpatient
OPPS/APC
Off Campus-
Hospital
Outpatient
OPPS/APC
Physician
outpatient
Services RBRVS/MPFS
Imaging
outpatient Centers (IDTF)
RBRVS/MPFS
POS 21 22 19 11 The setting the beneficiary
received the technical
component (TC) of the service.
Medicare
program
dollars Part A Part B
Local
Medicare contractors/ administrators
of the policies
Fiscal Intermediaries (old) Carriers (old)
Medicare Administrative Contractors (MAC) (Current)
www.cms.hhs.gov/medicarecontractingreform/
Abbreviations: APC, Ambulatory Payment Classifications; DRG, Diagnosis-
Related Groups; HOPPS, Hospital Outpatient Prospective Payment System;
IPPS, Inpatient Prospective Payment System; MPFS, Medicare Physician Fee
Schedule; RBRVS, Resource-Based Relative Value System, POS, Place of
Service IDTF, Independent Diagnostic Testing Facilities
POS 15 = Mobile Unit / Facility/ unit that moves from place-to –place
equipment to provide diagnostic and or treatment services.
Slide copyright MHCCC 2016
Medicare Payment Systems Basic Comparison of MPFS vs HOPPS
• MPFS is a system that pays for covered physicians’ services furnished to a person outside of a hospital.
• Under the MPFS a relative value (RVU) is assigned to each service to capture the direct and indirect (overhead) practice expenses typically involved in furnishing the service. AMA along with professional societies develop inputs and values by survey not claims data.
• The higher the number of relative value units (RVUs) assigned to a service, the higher the payment.
• Radiopharmaceuticals are paid at AWP or invoice cost.
• Drugs are paid at ASP + 6%.
• All services under the HOPPS are technical and are classified into groups called Ambulatory Payment Classifications (APCs) groups. Services in each APC are grouped by clinically similar services that require the use of similar resources.
• A payment rate is established for each APC using two year old hospital claims data adjusted by individual hospital’s cost to charge ratios.
• The APC national payment rates are adjusted for geographic cost differences with payment rates and policies being updated annually through rulemaking.
• Currently, diagnostic radiopharmaceuticals are bundled into the APC rate and considered supplies.
Charge (Description) Master
When to Update the CDM?
• Minimum Annual Update with Coding Changes
• October thru December each year
• Changes in Payer Guidelines or Instructions
• Changes in Technology
• Changes in Pricing
• Department Provides New Services or New Product Lines
• CMS Quarterly Updates (HCPCS & APC) Updates
• January, April, July, October
7
Diagnostic – Thyroid, Parathyroid & Adrenal
HOPPS National Rates Includes the Diagnostic Radiopharmaceutical(s) & Bundled Ancillary for CY 2016
APC rates will vary geographically. Figures used are not actual hospital payment rates.
CPT ® is a registered trademark of the American Medical Association
HCPCS
Code Descriptor
HOPPS
2013 Rate
HOPPS
2014 Rate
HOPPS
2015 Rate
HOPPS
2016 Rate
78014 Thyroid uptake & scan $232.94 $286.94 $281.89 $332.65 +18%
78070 Parathyroid planar $232.94 $286.94 $281.89 $332.65 +18%
78071 Parathyroid planar &
SPECT $322.04
CH APC 0317
$738.69 CH APC 0317
$377.18 CH APC 0263
$332.65 (-12%)
78072 Parathyroid planar &
SPECT /CT $322.04 $738.69 $377.18 $441.36 +17%
78075 Adrenal Imaging $955.60 $1,157.42 $1,188.28 $1,108.46 (-7%)
78195 Lymphatics $275.95** $346.34** $369.60** $332.65** (-10%)
**A9520 Lymphoseek packaged for CY 2016, off pass-through per statute.
8
Dept # Item # Limited Description CPT/HCPC RC Price Active
Code
Deactivation/
Date
302 55486 Tumor SPECT – (Parathyroid) 78803-TC 0341 $3,200.00 Y Maybe
302 55450 Parathyroid Imaging (planar) 78070-TC 0341 $1,800.00 Y Modified
302 55490 Parathyroid Planar + SPECT 78071-TC 0341 $3,200.00 Y New
302 55410 Parathyroid Planar + SPECT/CT 78072-TC 0341 $4,200.00 Y New
302 40335 Tc99m pertechnetate, per mCi A9512 0343 $100.00 Y
302 40350 Tc99m sestamibi, PSD A9500 0343 $500.00 Y
Charge Description Master
Parathyroid Imaging Effective 1/2013
PSD = per study dose
Price = example to show math and not derived from actual data
TIP: Maintain the tumor SPECT code unless you priced it differently from other
tumor imaging. Price for SPECT without CT should be different from SPECT with
CT for attenuation correction (AC) service Watch units for RPs.
®CPT is a registered trademark of the American Medical Association
9
What is “Charge Compression”?
• Hospitals do not mark-up high cost drugs in the
same way as they mark up lower cost drugs.
• Example low cost: 99mTc MDP $22.00, on CDM at $55
this is a 250% mark up
• Example high cost: PET agent $3,000.00, on CDM at
$3,500 117% mark up rather than $7,500.00
• Therefore when CMS uses one cost-to-charge
ratio for a hospital the costs of the higher cost
drugs or radiopharmaceuticals are undervalued for
rate setting.
10
Example I-123 mIBG AdreviewTM: CMS Data: Cost Versus ASP Plus 6
HCPCS
Level II
Total
Units Descriptor
Mean
Cost
Oct 2011
OPPS
Addendum B
File
F CY 2011
A9582 2012 Data
403
Iodine I-123 iobenguane,
diagnostic, per study
dose, up to 15 millicuries
$1,331.73
$2,636.16 A9582
2013 Data 402 $1,380.34
A9582 2014 Data
328 $1,455.44
11
G.E. (manufacturer of product) ASP Q2 2013 = $2,696.00
ASP+ 6
Pass-Through
The cost of this diagnostic radiopharmaceutical (A9582) is a significant
cost (CMS definition of >40%) to consider for any APC placement.
CMS should consider a policy to address nuclear medicine services that
are Radiopharmaceutical cost intense and likely low volume.
Example: I-123 mIBG AdreviewTM
APC Packaged Rates
Cost of RP = Loss to Hospital
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HCPCS Code Descriptor HOPPS
2013 Rate
HOPPS
2014 Rate
HOPPS
2015 Rate
HOPPS
2016 Rate
78075 Adrenal Imaging
$955.60 $1,157.42 $1,188.74
$1,108.46 78804 2 or more day Tumor Imaging
0331T &
0332T
Myocardial sympathetic innervation,
imaging, planar qualitative and
quantitative assessment;
And with tomographic SPECT
$679.68 Incl Dx RP,
WM & EF
$1,153.62 Incl Dx RP, WM,
EF, 93017, Stress
Agent
$1,140.54 Incl Dx RP, WM, EF,
93017, Stress Agent
A9582 Iodine I-123 iobenguane, diagnostic,
per study dose, up to 15 millicuries Packaged Packaged Packaged Packaged
CPT ® is a registered trademark of the American Medical Association
APC rates will vary geographically. Figures used are not actual hospital payment rates.
A9582
RP Cost (ASP Q2 2013)
HOPPS Payment 2016 Hospital Loss
$2,696.00 APC 5593 $1,108.46 ($1,587.54)
Example: Diagnostic Radiopharmaceutical
Off Pass-Through Status Cost of Dx RP will exceed APC packaged payment rate
**C1204 LymphoSeek Oct 2013 - A9520 CY 2014 & 2015 on pass-through per statute off-set applies; CY 2014 offset APC 0400,
$61.41, 0392 $71.31. CY 2015 offset 0400, $62.96, 0392 $73.88 CY 2016 Lymphoseek off pass-through status, RP is packaged.
HCPCS
Code Descriptor
HOPPS
2014 Rate
HOPPS
2015 Rate
HOPPS
P 2016 Rate
HOPPS
F 2016 Rate
78195 Lymphatics and lymph node $346.34** $369.60** $336.75
(-8.9%)
$332.65
(-10%)
38792 “Q1” Status
Inj, proc. Radioactive tracer
for ID of sentinel node $257.43** $280.27**
$254.47
(-9.2%)
$332.65
(19%)
A9520 Tc99 tilmanocept diag 0.5mci $240.00
ASP +6 Jan 1, 2014 rate
$497.00
ASP +6 Oct 1, 2015 rate
Packaged
Off Pass-
through
Packaged
Off Pass-through
13
A9520
RP Cost (ASP Oct 1, 2015) HOPPS Payment
2016
Hospital Loss
$497.00 APC 5591 $332.65 (-$164.35)
APC rates will vary geographically. Figures used are not actual hospital payment rates.
CPT ® is a registered trademark of the American Medical Association
Hospital Claim Cost Data 2012 & 2014
Used to set 2014 & 2016 Rates
14
Slow changes – HOPPS claims data
When prices increase it can take years to show up in payment rates
Pass-Through Payment for New
Procedures-Radiopharmaceuticals
Legislated: (CMS has no authority to modify)
• Diagnostic Radiopharmaceuticals do
qualify for transitional pass-through
payment status
• However, this is for minimum 2 years
not to exceed 3 years…then by CMS
policy would be bundled 15
IDEAS-Study.org
Diagnostic Radiopharmaceutical (Dx Rp) Payment Pass-Through or Contractor Priced
Must participate in CED Trial for Amyloid Agents
2016 HCPCS Level II Codes
HCPCS
Level II
Trade
Name
Company Description
2016
SI /
APC
2016
HOPPS
Payment
2016
MPFS
Payment
C9458 *A9599
Neuracec™ Piramal
NDC # 54828-001-30
Florbetaben F-18, diagnostic, per
study dose, up to 8.1 millicuries G
9458 $2,968.00 Contractor
Priced
Most likely at
Invoice Cost.
* This setting
typically does
not accept C
codes, use
A9599
C9459 *A9599
Vizamyl™ G.E. NDC #
17156-067-10 17156-067-30
Flutemetamol F-18, diagnostic,
per study dose, up to 5 millicuries G
9459 $3,135.00
A9586
Amyvid™ Lily
NDC #
0002-1200-01
Florbetapir F-18, diagnostic, per
study dose, up to 10 millicuries G
1664 $2,756.00
© 2010 MEDICAL LEARNING INCORPORATED / SLIDE 16 16
IDEAS-Study.org
Procedure Coding - IDEAS
CPT Code Description 2016 HOPPS National Rate
2016 MPFS NF National Rate
78811-Tc PET imaging; limited area (eg, chest, head/neck)
$1,285.17- $228.37 = $1,056.80
$1,285.17 OPPS CAP 78814-Tc PET w/ CT for AC and
anatomic localization imaging; limited area (eg, chest, head/neck)
2016 Off-set only applies for HOPPS setting technical: APC 5594 = $228.37
NF= Non-Facility, Physician Office, Independent Diagnostic Testing Facility Setting (IDTF)
Rates will vary geographically. Figures are national rates.
2. INITIATIVE ADDRESSING
CODING & BILLING ERRORS
18
RP to Procedure Code Edit Data
HOPPS Claims Analysis
19
RP to Procedure Code Edit
Project from claims Analysis
20
National Correct Coding Initiative
SNMMI working with NCCI contractor
• SNMMI Letter recommending diagnostic
radiopharmaceutical to procedure code edits was
sent to NCCI contractor and follow up meeting
February/ March 2015.
• NCCI contractor & CMS accepted SNMMI
recommended edits:
• NCCI version 21.3 implemented on October 1, 2015. Other
societies could have submitted comments by July 1, 2015 if they
disagreed with any of the edits, however none did.
21
Results: SNMMI Edit Project
Slow – Long term project
• CMS & the SNMMI have received many inquiries from
providers that had denied claims
• SNMMI and the NCCI contractor educated providers on
proper coding for the diagnostic and therapeutic
radiopharmaceuticals.
• Since CMS is using HCPCS codes for bundling payments in
APCs, the hope is that by educating the hospitals, CMS
hospital claims data will get better.
• This is a long term project, since in HOPPS CMS uses two
year old data to set payment rates.
3. ALTERNATIVE APC GROUP
CONFIGURATIONS
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CY 2015 CMS - Nuclear Medicine
Current APC Restructure # APC Group Title SI Payment
Rate 1 0308 Positron Emission Tomography (PET) imaging S $1,285.72 2 0317 Level II Miscellaneous Radiology Procedures S $812.89 3 0340 Level II Minor Procedures S $52.35 4 0377 Level II Cardiac Imaging S $1,140.10 5 0378 Level II Pulmonary Imaging S $440.17 6 0389 Level I Non-imaging Nuclear Medicine S $189.08 7 0390 Level I Endocrine Imaging S $189.85 8 0391 Level II Endocrine Imaging S $281.89 9 0392 Level II Non-imaging Nuclear Medicine S $280.16
10 0393 Hematologic Processing & Studies S $627.95 11 0394 Hepatobiliary Imaging S $372.91 12 0395 GI Tract Imaging S $326.83 13 0396 Bone Imaging S $332.18 14 0398 Level I Cardiac Imaging S $373.42 15 0400 Hematopoietic Imaging S $369.46 16 0401 Level I Pulmonary Imaging S $315.76 17 0402 Level II Nervous System Imaging S $557.03 18 0403 Level I Nervous System Imaging S $176.99 19 0404 Renal and Genitourinary Studies S $420.49 20 0406 Level I Tumor/Infection Imaging S $377.18 21 0407 Radionuclide Therapy S $276.82 22 0408 Level III Tumor/Infection Imaging S $1,188.28 23 0414 Level II Tumor/Infection Imaging S $706.45 24
Issues Identified
• Anecdotal hospital medical practice shifts driven by
cost of the Dx RP and HOPPS APC packaged policy • Decisions on performing PET for FUO (fever of unknown origin), rather than white
blood cell (WBC) studies, are being made because of APC cost structure.
• Patients are traveling greater distances for studies as smaller hospitals have stopped
performing services that would be at a large cost loss to the hospital.
• Consolidation or industry exiting nuclear medicine field
• Some Dx RPs (radiopharmaceuticals) are now single sourced
• – e.g., Technetium MAA, DTPA, Xenon
• Increased costs are not current in CMS HOPPS data due to a two to three
year lag
25
SNMMI Meet with CMS
February 2015
The SNMMI is greatly concerned for our patients as some
hospitals have stopped performing services and they are
forced to go elsewhere for their testing. We are also
concerned for innovation and sustained products as we
have seen companies such as Bayer, Siemens, GE Healthcare
(new oncology tracers,) and GlaxoSmithKline (Bexxar) exit or
reduce participation in the nuclear medicine
radiopharmaceutical market in recent years.
26
See letter sent to CMS as follow up to February 2015 meeting for details.
SNMMI Proposal CY 2016
Simulation 2014 P HOPPS Data
Nuclear Medicine Procedures
# SNMMI Procedure Group Title SI Simulation CY 2016 FR GM
Packaged RP GM 2014
Data
RP Groups at
$100 dollar Threshold
1 Level 1 Nuclear Cardiology Dx Imaging S $400.11 $397.15
2 Level 2 Nuclear Cardiology Dx Imaging S $1,188.67 $1,037.02
3 Level 1 Nuclear Medicine Dx Imaging (planar, limited etc) S $346.98 $304.21 4 Level 2 Nuclear Medicine Dx Imaging (More complex) S $361.88 $350.12
5 Level 3 Nuclear Medicine Dx Imaging (SPECT, WB, multiple) S $515.95 $397.16 6 Level 4 Nuclear Medicine Dx Imaging (SPECT, two day) S $1,181.30 $541.37 7 Nuclear Medicine Dx Non-Imaging S $248.20 $226.83
8 Nuclear Medicine Dx PET (All Pet, Cardiac and Oncology) S $1,366.67 $1,140.59
9 Radionuclide Therapy (All NM Therapy) S $286.57 $278.83
Dx = Diagnostic
GM= Geometric Mean
FR = Final Rule 27
SNMMI Proposal CY 2016
Nuclear Medicine Dx Rp Grouped APCs
# SNMMI Procedure Group Title
20 RPs remain packaged as under $95 Threshold
SI Simulation CY 2015 FR 2013 Mean Unit x
Average unit per day
Weighted Average
Sample Dx RPs in the
Rps APC Group
1 Level 1 Dx Radiopharmaceutical $95.00 to $200 S $146.17 A9505, A9504, A9500, A9502,
A9528, A9580, A9562, A9556,
A9554, A9551
2 Level 2 Dx Radiopharmaceutical $200.01.00 to $400.00 S $226.76 A9552, A9521, C1204/A9520,
A9526, A9532, A4642,A9553+
3 Level 3 Dx Radiopharmaceutical $400.01 to $800.00 S $498.66 A9555, A9557, A9569, A9508,
A9570, A9548, A9521, A9547
4 Level 4 Dx Radiopharmaceutical $800.01 to $1,200.00 S $951.23 A9542, A9544
5 Level 5 Dx Radiopharmaceutical $1,200.01 to $1,600.00 S $1,396.27 A9507 A9582 (asp avail),
A9572
6 Level 6 Dx Radiopharmaceutical $1,600.01 to $2,000.00 S None this year
7 Level 7 Dx Radiopharmaceutical $2,000.01 to $2,400.00 S $2,380.64 A9584 DatScan
8 Level 8 Dx Radiopharmaceutical $2,400.01 to $2,800.00 S $2,696.00 A9582 I-123 MIBG &
A9568 B-Amyloid
9 Level 9 Dx Radiopharmaceutical $2,800.01 to $3,200.00 S None this year
10 Level 10 Dx Radiopharmaceutical $3,200.01 to greater S None this year
Consider new SI for RPs that would remove offset to eliminate duplicate payment of RP. 28
CY 2016 CMS - Nuclear Medicine
Proposed APC Restructure
# CY 2016
APC
CMS Group Title SI Payment Rate
1 5591 Level 1 Nuclear Medicine & Related Services (CPTs 78071, 78195, 78206 liver SPECT and flow, 78264 & new GES codes, GBP studies)
S $336.75
2 5592 Level 2 Nuclear Medicine & Related Services (CPTs 75563, MRI.SPECT MPI single, adrenal , parathyroid SPECT/CT, PET limited, blood volume)
S $473.78
3 5593 Level 3 Nuclear Medicine & Related Services (CPTs SPECT MPI multiple, PET most, T codes, 3D brain SPECT, tumor WB, CSF study)
S $1,172.71
4 5661 Non-Imaging Nuclear Medicine (CPTs 38792, all therapy, 78999, Vit B, platelet survival, 78808, 78725)
S $254.47
5 5523 Level 3 X-Ray & Related Services (CPT 78445 vas flow)
S $199.70
6 5524 Level 4 X-Ray & Related Services (CPTs 78457-78458 Venous Thrombosis)
S $363.21
7 5525 Level 5 X-Ray & Related Services (CPTs 78456 Acute Venous Thrombosis)
S $666.94
29
HOPPS CY 2016 PET vs non PET
Simulation of Split for APC 5593
APC APC
Description
CMS
Singles
CMS Geo
Mean
WPA
Singles
WPA Geo
Mean
Simulation
Singles
Simulation
Geo Mean
5593 Level 3
NM
858,777 $1,238.90 860,244 $1,240.69 860,244 $1,240.69
5593A NM & Related non PET Level 3 split (0331T, 0332T,
78451, 78452, 78454, 78607, 78647, 78804)
599,138 $1,189.41
5593B NM PET Imaging Level 3 split (78459, 78491, 78492,
78608, 78811, 78812, 78813, 78814, 78815, 78816)
261,210 $1,366.67
30
Federal Register Vol. 70 No 141
page 42723 (July 23, 2014)
CMS States, “Notwithstanding our commitment to package as
many costs as possible, we are aware that packaging
payments for certain drugs, biologicals, and
radiopharmaceuticals, especially those that are particularly
expensive or rarely used, might result in insufficient payments
to hospitals, which could adversely affect beneficiary access to
medically necessary services.”
31
The SNMMI presented examples to CMS and the HOP panel.
SNMMI Proposal to CMS
CY 2017
• The SNMMI requested that CMS
reconsider and propose for public
comment period to implement APCs for
groups of diagnostic
radiopharmaceuticals that will be paid
separately from the nuclear medicine APC
procedure groups for CY 2017.
32
Consequences of CMS not
adopting the SNMMI proposal
• Burden to beneficiaries who are traveling to the
decreasing number of facilities that are performing
the low volume high cost NM services.
• Stifles innovation and expansion in the NM
community as costs for new diagnostic RPs are not
covered after pass-through ends.
33
SNMMI Recommendations to
HOPPS Panel August 2015
The SNMMI recommends the HOP Panel request that CMS:
• Develop diagnostic radiopharmaceutical APC groups
• Adopt the SNMMI proposal for 8 diagnostic NM procedure
APCs specifically: • Maintain distinct APC for all PET procedures (currently APC 0308)
• Maintain distinct APC for therapeutic nuclear medicine procedures
(currently APC 0407)
• Create a new non-imaging NM APC Group consistent with resources
• Create four new Levels of Nuclear Medicine APC procedure groups that
build on the resource consumption and time for the various nuclear
medicine services, such as Planar, Multiple imaging, Multiple Studies,
Multiple day services, and SPECT and SPECT/CT studies.
• Maintain two Nuclear Cardiology APC groups
34
APC HOP Panel and CMS
Questions to SNMMI
• What evidence do we have to prove that
bundling is affecting volume of services?
• What evidence do we have that patient
access is being shifted to other sites or
other imaging studies, due to hospitals
deciding, only on tracer costs, to stop
providing?
35
2016 - Nuclear Medicine Payment Rates
CMS HOPPS APC Restructure
# 2016
APC
CMS Group Title SI Payment
Rate 2016 1 5591 Level 1 Nuclear Medicine & Related Services
(CPTs 78070-1, 38792, 78195, 78206 liver SPECT / flow, 78264, 78265, GBP studies,
Vit- B, 78808, 78445, 78458 bilateral venous thrombosis, 78999)
S $332.65
2 5592 Level 2 Nuclear Medicine & Related Services (CPTs, MRI 75559.SPECT MPI single, parathyroid SPECT/CT, PET limited, blood
volume, 78457 venous thrombosis)
S $441.36
3 5593 Level 3 Nuclear Medicine & Related Services (CPTs 75563, 78451-2, 78456, acute venous thrombosis, adrenal 78075, Plat
Survival 78191,T codes, brain SPECT, tumor WB, CSF study)
S $1,108.46
4 5594 Level 4 Nuclear Medicine & Related Services (CPTs all PET, CMS reserves the right to put non pet in this APC in the future.)
S $1,285.17
5 5661 Non-Imaging Nuclear Medicine
(CPTs all therapy, 78725)
S $249.98
36
APC rates will vary geographically. Figures used are not actual hospital payment rates.
CPT ® is a registered trademark of the American Medical Association
SNMMI Coding and
Reimbursement Activities
• SNMMI Coding & Reimbursement Committee
• CPT Advisors to AMA CPT Editorial Panel
• RUC Advisors to AMA Relative Value Update Committee (RUC)
• Answers members direct questions
• Collaborate w/ industry for new & established NM studies
• SNMMI Coding Education
• Chapter meetings and Webinars, Assist NOPR & IDEAS
• SNMMI Coding Corner –Updates and Q&As
• Industry Forum and Legislative Activities
37
Industry Forum Initiative: Data Collection to Support a
Legislative Approach to APC Reform
Situation:
• CMS does not recognize negative impact in
utilization resulting from bundling policy (claims
data do not reflect major shifts after pass-through,
new RP’s have no claims trends)
• Slow uptake of new RP’s is potentially creating
access issues for Medicare beneficiaries
• Direct evidence on impact of new technology
adoption and patient access issues from
providers most desirable
Objective:
• Obtain direct provider feedback to determine extent
of impact of payment methodology
Industry Forum Initiative: Data Collection to Support a
Legislative Approach to APC Reform
Method:
• Robust independent survey instrument with
decision-makers in NM and Radiology
Considerations:
• Question logic and balance, geographic and
provider diversity, proper size and scope
• Evidence must be credible and compelling, and
meet the differing needs of both CMS and
Congress
Status:
• RFP’s have been initiated with qualified vendors
Next Step
40
• More to come.