Carriers struggle to implement coverage document
PET imaging advocates rejoiced last year when the Health Care Financing Administration agreed to reimburse Medicare providers for lung cancer indications. The announcement sparked renewed interest in the modality among patients, physicians, and manufacturers, which translated into higher PET and gamma camera sales in the U.S. in 1998.
But despite the increased attention to PET imaging, many PET centers have found their reimbursement requests mired in red tape as HCFA’s third-party carriers struggle to implement the new policy. The problem, some believe, has to do with the complexity of the reimbursement policy and the difficulty that some Medicare carriers face in implementing it.
In June 1998, HCFA announced that it would reimburse technical fees for FDG procedures used in certain lung cancer applications at a rate of $1980 (SCAN 6/10/98). The decision came after years of pressure from PET advocates, most prominently Sen. Ted Stevens (R-AK), chairman of the Senate Appropriations Committee. Working with Secretary of Health and Human Services Donna Shalala, Stevens negotiated with HCFA for the lung cancer payment and asked the agency to consider other applications (SCAN 1/14/98).
Experts estimate that there are approximately 175 active PET centers across the U.S., with 80 dedicated PET systems and 200 gamma cameras capable of conducting FDG imaging with coincidence detection upgrades (some facilities have both PET units and gamma cameras). However, many PET centers have yet to receive payment for lung cancer scans performed since reimbursement was approved. Industry advocates such as the Institute for Clinical PET of Foothill Ranch, CA, attribute the slow payment to a phalanx of causes, ranging from the complexity of HCFA’s coverage policy to the tedious process carriers must go through to add new codes to their databases.
“The coverage policy went into effect in January of last year,” said Jennifer Keppler, executive director of ICP. “It’s taking a while for the policy and the procedures to filter down to each Medicare carrier. So (reimbursement) is spotty across the country. From what I understand, this is typical of complex national coverage policies: When a national policy comes out, it can take up to a year to implement.”
Industry watchers suggest that HCFA’s coverage document for lung cancer PET has caused confusion for carriers, slowing the reimbursement process. Carriers have misunderstood the policy and the modifiers that describe eligible patients, and have struggled to incorporate the new policy coding into their databases. Because of this complexity, some providers are receiving letters from their carriers seeking proof that the scanners and radiopharmaceuticals used in procedures are approved by the Food and Drug Administration. In addition, some centers have been refused payment because they are freestanding facilities.
