Q&A with Kathy Francisco, The Pinnacle Health Group

It could possibly be every physician’s least favorite topic, but unfortunately reimbursement is a key component of practice management. Whether you’ve been offering APBI for years or you’re just starting out, overlooking key reimbursement considerations can significantly impact your ability to offer the benefits of 5-day radiation therapy to your patients.

Kathy Francisco of The Pinnacle Health Group – one of the nation’s leading reimbursement consulting groups – reveals what every physician needs to know about reimbursement for APBI.

What are the most common reimbursement considerations physicians need to take into account regarding APBI?

The most important thing is for physicians to be proactive about researching the coverage guidelines for APBI with the local payers. Coverage for APBI is not as large an issue as it used to be; however, payers may have different patient selection criteria that determine which patients they will provide coverage for and which they will not. With all the various APBI patient selection guidelines that have been published recently, insurance companies are looking closely at coverage criteria.

When starting an APBI program, it is the practice’s responsibility to know the coverage guidelines for every payer and to adhere to them. The physician must understand the contractual agreements they have in place with each plan and make sure the patients that are candidates for APBI meet the payer’s criteria for coverage. It is not recommended that the physician bill the payer and wait to see how they are paid for the procedure – be proactive.

What action can a physician take if they want to offer APBI to a patient who doesn’t fit within the payer’s coverage guidelines?

Don’t ever be afraid to contact the medical director at a payer and negotiate coverage for a patient who is a good candidate for a procedure. As the treating physician, you will understand exactly what the best treatment is for a patient. If a patient doesn’t fit into the plan’s coverage guidelines but the physician feels strongly that APBI is the best treatment option, the physician should pick up the phone and discuss possible coverage with the plan medical director. This should be a peer to peer discussion – physician to physician. Be prepared to discuss all other options for treatment and why you feel this is the best treatment for your patient.

If physicians continue to review the clinical benefits with payers, ultimately the plan may develop patient selection criteria and permit APBI without patient specific appeals from the physician to the payer medical director. There is a cost to the plan for this individual coverage review process.

Challenging the payer coverage guidelines and policy is beneficial to the patient and ensures that patients will receive the treatment that is in their best clinical interest. This is the process that is involved with any new technology. Remember that payers are not providing care to patients; the patient is coming to you to receive the best treatment possible. If you have the patient’s best interest at heart, you should be willing to fight for the patient to receive the best treatment available. The insurance plan implements coverage limitations because they are a business, but they are always willing to discuss the best treatment option for the patients who are members of their plan.

What are some strategies physicians can pursue to ensure they gain appropriate reimbursement for APBI?

Again, don’t be afraid to pick up the phone and discuss treatment plans and negotiate coverage with a payer. When you are researching your payer contracts to verify coverage for APBI, also confirm reimbursement levels. Do not hesitate to renegotiate reimbursement levels if you feel they are not appropriate for the treatment you are providing. Most insurance companies are more than willing to listen and review reimbursement levels with providers when requested.

You MUST gather appropriate information BEFORE you pick up the phone. Sit down with your practice manager and review the payer contracts and understand any limitations on renegotiation first. Then determine your costs for the procedure, including overhead, billing, technical staff, cost of the surgical suite, medical supplies, etc. A good benchmark is always Medicare reimbursement. This is public information so any payer can access this information, too. Payers do not expect to be in business to lose money, and they do not expect providers to treat patients when they lose money either. Do not be afraid to pick up the phone and explain why you need to renegotiate payment rates for APBI with payers.

What sort of reimbursement support does The Pinnacle Health Group provide?

We serve as a resource for hospitals, Ambulatory Surgery Centers, physicians and physician offices. Especially in this economy when many practices may be scaling back on staff, we provide the necessary support for a variety of reimbursement questions and issues. We can help determine current coverage criteria with a plan, assist office staff with appropriate coding for a procedure, review modifier use, or assist when a claim is denied or not paid correctly within contractual guidelines. We offer a hotline for coding advice where providers can contact us to ask questions about reimbursement. Pinnacle will contact insurance plans and determine coverage, coding or discuss payment issues – a process that can keep the physician or office staff on the phone for hours. Our team of certified hotline consultants believes that APBI should be available to patients who are candidates for this treatment and we are willing to fight for it!

What are the most common questions you receive regarding APBI?

Most questions received by the hotline are related to patient selection criteria or coverage. We receive a lot of questions from surgeons regarding modifier use, since they are performing multiple procedures in one day, but also receive a number of questions from the radiation oncology group performing the HDR treatment twice daily for five days. We have the resources and knowledge to help providers obtain the information necessary to code claims correctly in these situations.

It seems every year the CMS proposes a reduction in physician payments. What impact do you think this has on the quality of healthcare?

Since 1994, we have had four reductions in the conversion factor that impacts physician payments. Congress continually approves legislation that delays reductions in the physician payments that are mandated by the sustainable growth rate (SGR) formula. Congress is currently discussing options that may provide relief for physicians for the next 4-5 years. Currently there is temporary legislation referred to as the “Temporary Extension Act of 2010”.

It’s unfortunate because these reductions are creating an environment in which physicians have to focus on procedures that are profitable and reduces their ability to offer procedures to patients that are not appropriately reimbursed. Payers don’t understand that physicians do care about offering their patients the best clinical treatment option; it’s not always about the money. But the physician can’t continue to offer treatment options to patients if they are losing money every time. Just like the payers, physicians are in business to earn a living too. In the long run, it’s the patient who suffers because it becomes more difficult for the physician or hospital to offer and deliver the highest quality care and best patient option for treatment.

Do you have questions about reimbursement with SAVI?

Contact The Pinnacle Health Group at cianna@thepinnaclehealthgroup.com or toll-free (866) 369-9290 for assistance.

About Kathy Francisco

Ms. Francisco has over twenty years of managerial experience focused in reimbursement, payer relations and state and federal governmental affairs. Her areas of expertise include strategic and tactical reimbursement coverage and coding, policy development and implementation, sales and marketing support and legislative policy development. Ms. Francisco has taken a very active health policy role with numerous medical societies, industry trade associations and health care coalitions and been an invited speaker at state society meetings, state conferences and national society and professional health care meetings across the country as well as several international symposiums.