Situation

The CMS Hospital Outpatient Prospective Payment System (HOPPS) proposed regulations were released which recommended a decrease in reimbursement based upon claims data analysis in reimbursement for the High Dose Rate (HDR) brachytherapy APC. However, the basis for decreasing reimbursement was based on unreliable claims data resulting from the numerous changes in coding implemented under the HOPPS program. The reduction in the APC value threatened to limit the number of facilities that could offer HDR brachytherapy to patients due to the significant loss in revenue imposed by the proposed new reimbursement rate. The client contacted The Pinnacle Health Group to request support to provide CMS with appropriate data to update the cost of HDR brachytherapy.

Solution

After careful research The Pinnacle team analyzed CMS claims data as well as actual cost data from over 100 hospitals. It was discovered that the actual cost was three to four times the proposed value of the APC. It also determined that the methodology used to determine the appropriate value for the APC was flawed due to the many changes in coding under the HOPPS. Claims and utilization data provided by individual institutions and a survey from the company indicated that a higher cost basis per treatment was appropriate. Data also confirmed that hospitals lacked an understanding of the correct coding for HDR sources and brachytherapy catheters and needles. Data were presented to CMS to request a review of the payment rate for HDR brachytherapy.

Outcome

CMS reviewed the hospital data and their claims data file based on The Pinnacle team’s analysis and presentation. CMS then appropriately adjusted the payment rate for HDR brachytherapy allowing hospitals to continue providing this valuable treatment to patients.