Kathy Francisco

When a woman is deemed to be a good candidate for accelerated partial breast irradiation (APBI), a denial in coverage for the treatment can be troubling for both the patient and the physician.

Although there have been no significant changes in APBI coverage over the past year, payers are making very careful coverage decisions for all treatments, according to Kathy Francisco of The Pinnacle Health Group, one of the nation’s leading reimbursement consulting groups. In this article, she discusses how physicians should verify coverage prior to treatment, as well as steps both physicians and patients can take to appeal a coverage denial.

There seems to be a perception that some payers are increasingly denying coverage for APBI – is this true? If not, what is causing this opinion?

Payers are making very careful coverage and payment decisions for all treatments. Specific to APBI, payers see the volume of procedures increasing so they are very careful to make sure they are making informed coverage decisions, but there have been no significant changes in coverage or payment over the past year.

Have you ever heard of any cases where payers approve the procedure, but then deny coverage after the device is already placed and the patient has completed treatment?

Precertification for a procedure is never a guarantee of payment. If you request precertification, the payer is only confirming that the codes reported are payable for the patient’s insurance plan. We always recommend that the provider review the payer policy guidelines at the time of precertification to determine if the patient meets the medical necessity criteria outlined by the coverage policy. In many cases, a precertification can be authorized, but if the patient does not meet the specific patient selection criteria outlined in the medical policy, the service would be denied as ‘not medically necessary’ or ‘outside the scope of the coverage policy guidelines’.

If coverage is denied, what are the most common reasons given? Is there something physicians can do to avoid a coverage denial?

There are two important steps in the reimbursement process that should be taken prior to scheduling the patient for the procedure. First, you should always confirm that the patient’s benefits are active and cover the procedure. During benefit verification, the provider can also ask if the specific CPT codes to be reported will be covered under the patient’s plan. In most cases this information can be provided, but be aware that some plans do not provide this level of detail. Second, always check the payer’s policy to review the specific patient selection criteria required to permit coverage for the patient.

What steps should physicians take to appeal a coverage denial? What type of information and/or resources can they provide to the payers to assist with the decision?

There is legislation to help patients and physicians with denied health care coverage decisions. The Affordable Care Act gives patients the right to appeal coverage decisions made by their health plan, although there are some limitations related to the Act that you will need to be aware of. The plan is required to permit an internal appeal process, which is a review process within the plan itself. If a service is still denied after the internal appeal, you have a right to elevate your request to an external appeal or an independent review organization that will make a decision to uphold or overturn the plans decision. Each plan is required to inform patients and providers about the appeal process, and beware that different plans have different rules. Each state also has a Consumer Assistance Program available to help with issues related to insurance denials and appeals.

The Pinnacle Health Group assists hospitals, physicians and other providers through the appeal process by outlining the steps available to the provider of services as well as the patient. We generally recommend that appeals be submitted to the plan from both the provider and the patient. The provider can provide the plan with information related to the medical necessity of the procedure and the reason the treatment was selected as the most appropriate for the patient.

The patient can provide the plan with information regarding the options that were made available and why one was selected over the other. For breast conserving treatment, patients have a choice of treatment options that range from one day, five days or seven weeks of therapy. A patient who needs to return to work may select an option that would allow the patient to be back within one or two weeks following surgery, rather than a longer course of therapy that may keep them out of work longer. The final decision as to which treatment option might be best for the patient should be clearly outlined to the payer during the appeal process, including the ability to return to work. If the treatment has been completed, it is always beneficial to outline the successful outcome for the payer as well.

Personally, since MRI overestimates the disease so frequently, I rarely rely on MRI-determined extent of disease to dictate the surgery I perform. I would rather perform a smaller surgical procedure and allow the histology of the tissue obtained, including margin-assessment, to decide whether further surgery is necessary. I feel like I conserve many more breasts that way.

Are there significant changes to the reimbursement for APBI in 2013? How will these impact physicians who offer this treatment?

The changes for 2013 related to APBI are very minor for physicians, hospitals and patients. APBI reimbursement has been quite stable for the past five years and there is no expectation that the reimbursement will change significantly. Most patients who are candidates for APBI are working women and a 5-day treatment proves to be the best option for them in today’s economic environment. The treatment is reimbursed by almost every payer, and supports the women who need to get back to work faster and with lower out-of-pocket expense

About Kathy Francisco

Ms. Francisco is a managing partner of The Pinnacle Health Group, Inc. She 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. For more information, visit www.thepinnaclehealthgroup.com.