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Role of the Urologist and Insurance Coverage
CMendey
Posted: Monday, November 02, 2009 11:43 AM
Joined: 11/2/2009
Posts: 4


Hello CyberKnife Fans!

I work as a billing/coding rep for a large Urology group in Kentucky. We have been using CyberKnife through the local hospital for about three years but with the deletion of CPT code 61793 last year we have now found we no longer get paid for our participation in CyberKnife therapy other than the "set up".

Several of our Doctors have voiced that since they receive compensation for participation in other forms of brachytherapy then CyberKnife should not be excluded. However, most of the more recent determinations from major medicare carriers such as Highmark (who will take over our region starting in December) see it otherwise. We have no plans to stop recommending it as an option to our patients - so far it has proven to be too good not to, but it does make our physicians a little hesitant to get too involved with it, and our patients a little hesitant to consider it.

Currently National Government Services (our current Medicare carrier) has not made any official decision regarding the role of the Urologist/Surgeon and any reimbursement that we are aware of - they are simply holding our claims pending review.

I am not a clinician, and was wondering if anyone could clarify the role of the Urologist durring treatment delivery itself. So far the argument with the insurance companies seems to be that if they don't "push the button", they don't get paid for it.  Opinions?

Are there other Urology practices having the same or similar issues and what has been the result so far?


radsrus
Posted: Monday, November 02, 2009 3:08 PM
Joined: 10/10/2008
Posts: 4156


Urologists help define the target and at-risk areas and are involved to variable degrees in the treatment planning. They also take care of the patient after treatment. IN many cases they place the gold fiducials in the prostate.

Radiation oncologists also don't "push the button".

This is a nationwide problem and is being worked on at the highest levels.


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


Dr. J
Posted: Monday, November 02, 2009 8:04 PM
Joined: 10/11/2008
Posts: 1070


I have, on occasion, pushed the button...

 

Jerome J. Spunberg, M.D., FACR, FACRO
CyberKnife Center of Palm Beach
jspunberg@radiationoncologyinstitute.com
(561) 799-2828

 

Radiation Oncology Institute
10335 N. Military Trail, Suite C
Palm Beach Gardens, FL 33410
(561) 624-1717


radsrus
Posted: Tuesday, November 03, 2009 2:54 AM
Joined: 10/10/2008
Posts: 4156


I have too, but don't want to make a habit of it.


 

Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org

Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102

 


CMendey
Posted: Tuesday, November 03, 2009 4:55 AM
Joined: 11/2/2009
Posts: 4


Yes you must be careful when pushing buttons....

Please dont be offended by the "push the button" comment - that was an actual quote I got from an insurance company rep when they were trying to explain why the Urologist would not be covered.

Thanks for the responses. I have read several news reports where they show the Urologists are being paid $1200 for the treatment delivery but we are certainly not seeing that. We do receive payment for the planning and placement of fiducials but the insurers are hesitant to include us in the procedure itself.  Since the deletion of the old code, the only payment received from Medicare was for $25, and I fully expect that to be re-couped.

Whether or not we receive any reimbursement we will still continue to offer it as a treatment option to our patients. The feedback we have received from our patients has been amazing and so long as the long term studies stay positive, we really hope this will become one of the standard treatment methods.


viperfred
Posted: Tuesday, November 03, 2009 8:52 AM
Joined: 10/10/2008
Posts: 792


CMendey thank you for putting your prostate cancer patients well being ahead of profit. It is unfortunate that our insurance providers(private including medicare) are the largest obstacles to quality health care access. Health care insurance companies are a blemish on our society and provide very little value. Most Doctors put optimal care to their patients ahead of personal economic benefit. But speciality societies act different than individuals putting economic interest ahead of patient care. How can we fix health care? This is a very complex problem that must be addressed to improve care access and lower overall cost. Health care providers and patients must work together to correct the incompetence and gross negligence of Insurance companies including the Medicare providers. The insurance complex are experts creating conflicts between Doctors, Health care centers and patients. The follow a divide and conquer strategy. I know of a hospital that worked with a patient to fight an insurance denial for CK treatment of PCa. Working together the prevailed. This is one example of how to address this problem. Political changes must be made at the state and federal level to support patient access to innovation. We can reduce the incompetence and gross negligence of Insurance companies. Fred
CMendey
Posted: Tuesday, November 03, 2009 9:13 AM
Joined: 11/2/2009
Posts: 4


Thanks Fred!  

I have been reading your posts on here and I just wanted you to know what an amazing and inspiring person you are. I wish all our patients were as motivated as you are to get involved in taking on the insurance companies. Imagine the good that could be brought about if everyone took their insurance coverage more seriously and stood up for their rights as patients and policy holders.            

              


Dr. J
Posted: Wednesday, November 04, 2009 3:48 AM
Joined: 10/11/2008
Posts: 1070


Well said!

 

Jerome J. Spunberg, M.D., FACR, FACRO
CyberKnife Center of Palm Beach
jspunberg@radiationoncologyinstitute.com
(561) 799-2828

 

Radiation Oncology Institute
10335 N. Military Trail, Suite C
Palm Beach Gardens, FL 33410
(561) 624-1717


viperfred
Posted: Wednesday, November 04, 2009 5:37 PM
Joined: 10/10/2008
Posts: 792


Thanks!
 

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