Practice Manager Insider

Genomic Health Says Medicare Will Cover Oncotype DX

Genomic Health’s Oncotype DX is a laboratory test that quantifies the likelihood of breast cancer recurrence in women with certain types of early-stage invasive breast cancer. The coverage decision covers women with node-negative breast cancer who have estrogen-receptor-positive tumors. The test must be used within 6 months of diagnosis. Intent to treat or not treat with adjuvant chemotherapy should be contingent, at least in part, on the test results. Coverage is scheduled to become effective for claims deriving from services performed on or after February 27, 2006.

The decision was issued by the National Heritage Insurance Company (NHIC), the contractor administering Medicare programs in California. Medicare bills for Oncotype DX are billed through NHIC because the test is conducted by Genomic Health in its Redwood City, CA, clinical reference laboratory.

Genomic Health announced on January 27 that the FDA has invited the firm to a meeting in order to discuss the regulatory status of the company’s technology. Oncotype DX entered the market in 2004. The FDA had indicated in December 2004 and in 2005 that it was evaluating whether Oncotype DX was subject to premarket regulatory review.

Recent JCO Report: Change in Medicare Drug Reimbursement Could Result in Significant Income Loss

This finding comes from a review by McKoy, Bennett and colleagues published in the December 2005 Journal of Clinical Oncology. Last year, after settlement of a fraud investigation and related criminal charges, Medicare shifted the basis of its reimbursement to Average Sales Price from Average Wholesale Price (AWP). Authors state that this change is expected to significantly impact outpatient oncology practice. This change is expected to produce an 8% decrease in mean revenue for oncologists and a decrease in physician reimbursement for cancer drugs. The JCO study estimates annual income loss for oncologists.

Medicare officials and some in Congress had long criticized use of AWP as a basis for reimbursement, charging that it resulted in reimbursement above the purchase price. Some have argued that the margin covered the underpayment for the costs of office-based infusion and that reimbursement based on ASP would lead to financial losses.

How Have Medicare Changes Affected Access to Care? Here’s a Chance to Help Find Out

Many have argued that Medicare changes will worsen cancer patients’ access to care in the community, outside of hospital and academic settings. The Community Oncology Alliance (COA) is attempting to document the impact and plans to present findings to members of Congress.

Community-based oncology practices can sign up on the COA website to participate in the data gathering. The 7-question form seeks information about whether a practice is referring out for chemotherapy due to Medicare changes, availability of chemotherapy administration facilities that do accept Medicare, whether patients have been denied medication through Medicare Part D, and whether a practice accepts Medicare patients at all. Practices are asked to specify the number of patients affected (eg, how many are referred for chemotherapy because of Medicare payment changes) and update this every week. Information will be used only in a statistical format.

About 60 practices have signed up to participate in the roughly 2.5 weeks that the link for signups has been available, said Kelli Barron, director of development and communications for COA.  COA intends to present the data to members of Congress next week. “We wanted to monitor what’s going on with the new Medicare rules,” she explained. “Everyone says it’s not working. Having hard data is a lot more effective.”

Besides quantifying the impact of Part D, the survey seeks information about changes due to the reimbursement of medications infused in the office as average sale price (ASP) plus 6% rather than average wholesale price (AWP). This long-discussed move took effect on January 1, 2006, Barron said.

Register for ASCO’s QOPI by February 15; Meet a Recertification Requirement

February 15 is the deadline to participate in the first of 2 elements of the ASCO Quality Oncology Practice Initiative (QOPI). This program involves a twice-yearly retrospective chart review using quality measures and data submitted through a secure ASCO website. QOPI was piloted in 2005; 2006 will be the first year that any ASCO member can sign up.

Participation has the benefit of satisfying the American Board of Internal Medicine (ABIM) 2006 practice performance improvement requirement for maintaining certification. QOPI is the only oncology-specific program approved to meet this requirement. Oncologists, internists, and most subspecialists certified in 1990 or later must complete a practice improvement module to maintain certification.

Oncologists using QOPI as part of recertifying would participate in the first QOPI chart review, set goals for performance improvement, and submit that information to an ABIM web page. Following the second QOPI data collection, participants report to ABIM about progress toward meeting their goals and experience with the process of implementation.

Interview: Techniques for Effective Management of Accounts Receivable

The survival of an oncology practice depends more than ever on efficient collection of accounts receivable. Practice Manager Insider interviewed editorial board member, Patricia Falconer, MBA, president of Health Options, on specific strategies practice managers can use to effectively handle accounts receivable collection.

Listen to an audio recording of the interview here.

Detailed Information on 2006 Demonstration Project

In late December, CMS announced that it would implement the Medicare Oncology Demonstration Project for 2006. Its purpose is to identify and assess certain oncology services provided in office-based practices that affect outcomes in Medicare patients. CMS has developed two publications that detail information on this year’s Demonstration Project. The first, SE0589, covers information on Medicare policy and claims processing as it applies to the Demonstration Project. The second, SE0588, provides guidelines on documentation and coding.