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    What happens when prior auths don’t match services provided?

    Obtain revised prior authorization and submit to payer as soon as possible

     

    I am working on a new device to assist in the instillation of drugs into the bladder. Can you tell me how a device like this will be reimbursed?

    Without knowing the specifics of the device and where you are with the FDA and other regulatory hurdles, we will answer the question generally as we understand the device and how policies pertain to reimbursement of drugs and supplies used during the performance of a procedure.

    The current Medicare fee schedule used by Medicare and most private payers will include payment for supplies and equipment required to complete an approved procedure. In other words, payment for procedures completed in the office will be paid to the physician’s office submitting the claim without separate facility payment and will include payment in most cases for all clinical staff, medical supplies, and equipment. One exception to this inclusion rule is payment for drugs purchased and delivered to the patient in the office, which are not typically self-administered.

    Therefore, based on our understanding of your product, your delivery device would be included in the allowed amount currently listed for the CPT code used to deliver the drug (51700, 51720, etc.). The drugs delivered to the patient could be reported separately.

    Also see - Telemedicine: Reimbursement in fee-for-service, quality models

    The ambulatory surgical center, hospital inpatient, hospital outpatient, skilled nursing facility, etc. will charge separately from the physician. The physician payment at the lower facility rate would not include supplies and/or drugs required during treatment. Instead, the facility would report a service charge related to the procedure or diagnosis that would include a bundled payment for the staff, supplies, and equipment. Again, based on our understanding of your device, no separate payment would be made to the facility for your device.

    Offices interested in using your device will have to consider the cost difference between your device and the costs they have currently. In today’s market, though, cost considerations should take into account both the fee-for-service market and the value-based market pressures. In a fee-for-service market, cost considerations will focus on time for personnel, room time (opportunity cost), and device cost.

    In a value-based market, the office will also need to consider the value of any increased efficacy of treatment, patient satisfaction, and long-term complication and compliance improvements. The actual dollar value of each of these issues will vary according to contract and packages.

    Good luck and feel free to reach out again if we can be of more assistance.

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    Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at [email protected] Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.


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    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.

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