Strategic Radiology shares concern about inconsistencies in MAC payment determinations
Strategic Radiology, a coalition of independent imaging groups, is sharing concern about inconsistencies in how Medicare Administrative Contractors make payment determinations.
Back in July with the release of the physician fee schedule, CMS highlighted efforts to “alleviate confusion” about payment for radiopharmaceuticals in the office-based setting. The agency confirmed that, when delivering these drugs outside of hospital outpatient departments, MACs would determine pay limits based on any methodology in place on or prior to November 2003. This could include the use of invoice-based pricing.
In comments submitted to the agency this month, Strategic Radiology noted that practices have reported inconsistencies in how MACs calculate and cover these reimbursements. While contractors are required to provide coverage for radiopharmaceuticals listed in National Coverage Determinations, they have flexibility to set their own policies for other drugs.
“This flexibility results in significant coverage variations across jurisdictions, where patients might get a covered scan in one area but have to pay out of pocket in another for the same procedure,” SR CEO Scott Bundy, MD, wrote to the head of the Centers for Medicare & Medicaid Services. “Even where coverage is consistent, reimbursement practices can differ.”
Bundy highlighted amyloid PET scans for dementia and Alzheimer’s as one example. Providers in outpatient settings have reported issues with WPS Government Health Administrators, which serves jurisdictions 5 and 8, including Iowa, Kansas, Missouri, Nebraska, Indiana and Michigan. The MAC currently is not covering the tracer’s cost and is reimbursing significantly below the expense.
“WPS appears to be disregarding average wholesale price guidelines, and repeated appeals have not resolved this issue,” Bundy wrote. “As a result, some providers cannot offer this crucial diagnostic exam due to inadequate reimbursement, affecting Medicare beneficiaries in the affected regions. Strategic Radiology respectfully requests that CMS revise its directive to ensure uniform calculation and coverage of radiopharmaceutical reimbursements across all MACs, thereby guaranteeing that providers are appropriately reimbursed for their costs.”
This was one of several issues raised in the letter, which also touched on the 2.8% conversion factor reduction, CT colonography coverage and virtual presence for diagnostic tests. You can read the whole comment letter here.
Strategic Radiology represents 40 privately owned, independent practices employing 1,800-plus physicians, most recently adding Rhode Island Medical Imaging.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.