#FixPriorAuthNow: ASTRO Prior Authorization Advocacy and Resources

By Howard Sandler, MD, MS, FASTRO, and Constantine Mantz, MD, FASTRO

ASTRO members are frustrated by the scourge of restrictive and burdensome prior authorization requirements that frequently result in care delays or outright denials of coverage, and ASTRO is dedicating significant advocacy resources, across the Health Policy and Government Relations Councils, to this issue.  In member surveys, radiation oncologists consistently rank prior authorization as the top challenge facing practices, and ASTRO has conducted and publicized numerous studies demonstrating the negative impact of prior authorization on patients and practices.

The Health Policy Council’s Payer Relations Committee (PRC) engages with Radiation Oncology Benefit Managers (ROBM) and payers to educate them on appropriate coverage and directly advocate on behalf of members that are experiencing delays or denials for standards of care that are reasonable and appropriate. In addition to regular communications with ROBMs and payers, ASTRO issues Model Policies for each radiation therapy modality of treatment that are designed to educate payers on appropriate coverage based on clinical evidence. ASTRO also provides ROBMs and payers with a copy of the ASTRO Radiation Oncology Coding Resource and access to webinars that detail appropriate coverage policies. Despite these efforts, ASTRO members continue to face restrictive coverage policies, some of which are described below.

eviCore, a ROBM that contracts with many payers, has determined that conventional fractionation schemes for breast and prostate cancer are no longer medically necessary. They will only approve hypofractionation, which is a shorter course of treatment, for these two disease sites. This restrictive policy ignores the fact that some patients have certain clinical characteristics that are more suitable for longer course treatments. ASTRO has pushed back on this policy, as it is merely designed to save money.  Additionally, it does not take into consideration the clinical characteristics of the patient, nor does it recognize the important role of shared decision making between a doctor and their patient. Despite our efforts, eviCore refuses to reconsider this policy.

Another issue ASTRO frequently hears about is complaints regarding eviCore’s peer-to-peer reviews. These coverage determination reviews have increased dramatically during the COVID-19 PHE, consuming significant amounts of physician time and causing a high level of frustration. ASTRO members frequently report that peer reviews often involve a physician that is not a radiation oncologist, resulting in inappropriate denials and delayed care. In order to help address the issue, ASTRO has devoted a section of its website to house sample ROBM appeal form letters that radiation oncology practices have successfully used to appeal denials. This allows practices across the radiation oncology community to share letters with other radiation oncologists to help save time and administrative burden associated with growing denials and delays in care.

Private payers are also utilizing prior authorization as part of their coverage review process. ASTRO has written numerous letters to payers about inappropriate prior authorization denials and restrictive medical policies. ASTRO sent a comment letter to eviCore on their oligometastases policy, after several members reported receiving denials that did not align with current guidelines.

UnitedHealthcare (UHC) recently announced the establishment of a prior authorization electronic portal for approval of all the following services: IMRT, PBT, SBRT and IGRT; “Special and Associated radiation therapy services;” and fractionated breast, prostate and lung cancers, and bone metastasis. This list encompasses a significant portion of the services delivered by radiation oncologists. ASTRO’s Payer Relations Committee, Health Policy Committee and Clinical Affairs and Quality Council met with UHC to emphasize the negative impact this policy would have on radiation oncologists and their patients. UHC made modest modifications; however, members still report delays in patient care and other administrative burdens despite the electronic format.

ASTRO supports professionally developed and vetted clinical practice guidelines, appropriateness of care criteria, and consensus-based model policies developed in a transparent manner with peer review and input as a foundation for clinical decision making. We oppose restrictive practice guidelines that oversimplify the process of individual patient management and abrogate the professional judgements that are often only possible within the private boundaries of a direct patient-doctor relationship.

With prior authorization out of control, one of ASTRO’s top advocacy priorities is to push Congress and Medicare to intervene. ASTRO has sent numerous letters to the Centers for Medicare and Medicaid Services describing how restrictive prior authorization practices are keeping patients from the care they need and the care they have paid for in premiums. Congress is getting closer to passing ASTRO-backed legislation to enact significant prior authorization reforms. Passage of the Improving Seniors Timely Access to Care Act may possibly occur later this year, as now more than 330 representatives and senators have cosponsored the bill. The bill was a priority focus during ASTRO Advocacy Day, as radiation oncologists pressed their members of Congress during more than 100 meetings in May to advance the legislation.

ASTRO is committed to reining in excessive prior authorization, and we encourage members to voice their concerns directly to members of Congress via ASTRO’s grassroots system and social media. If you are experiencing difficulties with eviCore or payers, please contact Emilio Beatley, ASTRO Health Policy Analyst, so we can provide resources and engage on your behalf.

Posted: June 8, 2022 | 0 comments

Get the Scoop on Radiation Oncology Coding

By Jan Dragotta, Radiation Oncology Services Director, Princeton Radiation Oncology, Astera Cancer Care

ASTRO’s annual Coding and Coverage Seminar is an excellent opportunity for those involved in the field of radiation oncology to gain more insight into CPT® coding guidance, billing practices and the evolving challenges medical professionals face in the radiation oncology field today. As an attendee of the Coding and Coverage Seminar, I was surrounded by professional coders and billers, practice administrators and radiation oncologists who experience these same challenges every day. The ASTRO virtual Coding and Coverage Seminar allows for engagement and discussion among participants, which is invaluable, particularly as practices find themselves spread thin and unable to travel due to COVID-19. Attendees have direct access to ASTRO faculty and staff, and I was impressed with the ease with which questions were answered and dialogues transitioned to group discussions throughout the program and after.

As someone who has attended the Coding and Coverage Seminar, I can speak to how highly interactive and informative the sessions are. The ASTRO faculty involved in the seminar included subject matter experts who write ASTRO’s Coding Resource, which serves as a textbook for the seminar and benchmark for best practice. It is a wonderful opportunity to engage in conversations and interact on coding issues, with a heavy emphasis on the clinical process of care. Case studies are presented on intensity-modulated radiation therapy, brachytherapy, proton beam therapy and stereotactic radiosurgery/stereotactic body radiation therapy for a variety of disease sites. These studies are a great tool for discussion and help attendees learn how to apply their newfound coding knowledge and provide specific coding guidance related to each scenario.

The seminar is a wonderful way to not only understand how to correctly use the CPT codes for radiation oncology, but to also understand some background information on the process of code development and valuation. Specific coding changes that are set to occur in the new year are discussed, and attendees can ask questions and gain clarity on this complex subject, helping practices avoid coding and billing errors. Faculty of the Coding and Coverage Seminar genuinely enjoy the opportunity to engage with attendees and help them navigate some of the more complex nuances of radiation oncology coding.

Additional topics covered during the seminar include sessions on the RO Model and Merit-based Incentive Payment System (MIPS), payer policy changes and other hot topics impacting the field of radiation oncology.  It’s a day well worth spending with ASTRO! I would encourage anyone with a responsibility for coding and those who want to learn more in order to grow within their profession to register for the upcoming December 11 event. An added bonus is that the electronic and hard copy versions of the ASTRO Radiation Oncology Coding Resource is included with your registration, an invaluable reference both during and after the program.

Posted: November 9, 2021 | 0 comments

Whether in or out of the RO Model, 2021 Could be a Struggle for Radiation Oncology

By Anne Hubbard, Director, Health Policy, and Bryan Hull, Assistant Director, Health Policy

Proposed Medicare payment policies set to start January 1, represent significant financial challenges for radiation oncology practices as they enter the new year, regardless of whether or not your practice is participating in the Radiation Oncology Alternative Payment Model (RO Model). Despite many practices experiencing revenue declines of 20-30% in 2020, the Centers for Medicare and Medicaid Services (CMS) is pushing ahead with massive cuts for radiation oncology and other specialties.

In August 2020, CMS issued the 2021 Medicare Physician Fee Schedule (MPFS) proposed rule effective January 1, 2021. The MPFS proposed rule includes significant cuts that will be implemented broadly across the field of medicine. Subsequently, on September 18, 2020, the Center for Medicare and Medicaid Innovation (CMMI) issued a final rule establishing a Radiation Oncology Alternative Payment Model (RO Model), effective January 1, 2021. The RO Model also includes significant payment cuts due to the payment methodology that involves discounts and withholds.

ASTRO is fighting hard to reverse these pending cuts, which are unwarranted and will potentially lead to serious access to care issues across the country. We have engaged ASTRO’s congressional champions and have contacted the highest levels of leadership within the Department of Health and Human Services to intervene. That said, ASTRO members must be aware of just how dire the consequences are for the field. Below is an overview of what practices can expect in 2021. Be forewarned, the outlook is grim.

Medicare Fee-for-Service Payments

Under fee-for-service payments, which will continue to apply to the professional component payments of those practices not participating in the RO Model, providers are paid according to patient care delivered based on the provisions of the MPFS. The Impact Table below (Table 90 of the 2021 MPFS proposed rule) shows the estimated impact on total allowed charges for radiation oncology based on the relative value unit (RVU) changes contained within the proposed rule.

The expected impact on radiation oncology is a combined reduction of 6% on payment rates for 2021. These reductions are specifically related to modifications of the Evaluation and Management (E/M) codes that create a shift in payments across all specialties resulting in a reduction to the Conversion Factor (CF) of more than 10% to comply with the statutorily mandated budget neutrality requirement.

Table 90: CY 2021 PFS Estimated Impact on Total Allowed Charges by Specialty

Specialty Allowed Charges (mil) Impact of Work RVU Changes Impact of PE RVU Changes Impact of MP RVU Changes Combined Impact
Radiation Oncology and Radiation Therapy Centers $1,803 -3% -3% 0% -6%
Total $96,557 0% 0% 0% 0%

Upon closer analysis, the budget neutrality adjustment results in even greater variation across radiation oncology services. For instance, CPT code 77014, Computed tomography guidance for placement of radiation therapy fields, is expected to see an 11% reduction in payment under fee-for-service billing in 2021. In addition, CPT code 77301, IMRT plan, including dose-volume histograms for target and critical structure partial tolerance specifications, is expected to see a 7% ($129.76) reimbursement cut for 2021. Of note, CMS proposed RVU increases for several key radiation oncology codes; however, the budget neutrality adjustment largely offset those increases. The table below demonstrates the impact of the CF reduction on key radiation oncology services.

CPT Code CPT Descriptor 2020 National Rate 2021 Estimated National Rate 2021 Impact
77014 CT scan for therapy guide $46.20 $40.97 -11%
77300 Radiation therapy dose plan $33.56 $30.00 -11%
77301 Radiotherapy dose plan IMRT $432.72 $387.12 -11%
77334 Radiation treatment aid(s) $62.80 $55.49 -12%
77014 CT scan for therapy guide $124.51 $117.75 -5%
77263 Radiation therapy planning $174.31 $156.14 -10%
77290 Set radiation therapy field $508.15 $472.93 -7%
77300 Radiation therapy dose plan $67.85 $62.58 -8%
77301 Radiotherapy dose plan IMRT $1,949.22 $1,819.46 -7%
77336 Radiation physics consult $81.20 $78.71 -3%
77338 Design MLC device for IMRT $497.32 $448.09 -10%
77373 SBRT delivery $1,230.67 $1,110.39 -10%
77427 Radiation tx management x5 $196.33 $175.82 -10%
G6002 Stereoscopic x-ray guidance $76.51 $72.26 -6%
G6012 Radiation treatment delivery $262.74 $251.31 -4%
G6013 Radiation treatment delivery $263.10 $251.95 -4%
G6015 Radiation tx delivery IMRT $369.92 $365.83 -1%

ASTRO is engaged in a comprehensive advocacy campaign to mitigate or postpone the expected cuts for 2021. In collaboration with a broad coalition of physician and non-physician health care provider organizations, ASTRO has urged Congress in a letter to waive the budget neutrality requirement for 2021 in any forthcoming health-related legislative package to provide relief from the reimbursement cuts associated with the MPFS updates. ASTRO’s congressional allies have also been contacted and are aware of the significant impact these cuts have on the profession. In addition to congressional action, ASTRO provided CMS with substantial comments in response to the 2021 MPFS proposed rule addressing how the budget neutrality adjustment poses a significant threat to the profession, which is already suffering significant losses as a result of the COVID-19 public health emergency (PHE). ASTRO urged CMS to use its authority under the PHE to waive the budget neutrality requirement for at least another year, allowing practices time to recuperate from significant losses already suffered in 2020.

RO Model Payment Rates for 2021

For those practices required to participate in the RO Model, it’s bad news as well. ASTRO has documented and is advocating for significant changes to the RO Model payment methodology, which layers a series of deep cuts on participants. But one aspect of the RO Model payment methodology, a “Trend Factor,” is influenced by the MPFS and Hospital Outpatient Prospective Payment System (HOPPS) and deserves greater scrutiny in light of the PFS cuts discussed above.

The Trend Factor serves as an annual update to the payment methodology by reflecting utilization and payment changes outside the Model, i.e., the MPFS and HOPPS. For 2021, the Trend Factor will use 2018 utilization data and 2021 MPFS and HOPPS data to establish an update to the RO Model payment methodology. Due to the anticipated reduction in the 2021 MPFS rates, the Trend Factor is likely to put additional undue financial strain on radiation oncology practices participating in the Model.

Practices participating in the RO Model are already subject to discount factors of 3.75% off the Professional component payment and 4.75% off the Technical component rates, as well as payment withholds for quality measures performance and incorrect payments. These reductions will be compounded by a low or potentially negative Trend Factor. This “double whammy” rate reduction is a disservice to practices that are compelled to participate in the Model, which is particularly disappointing given that the purpose of the RO Model was to establish rate stability over time. By establishing a Trend Factor that fluctuates based on the whims of the MFPS and HOPPS, CMS has effectively eroded the stability that practices thought they might be able to secure under the RO Model.

ASTRO has raised concerns regarding the RO Model’s aggressive implementation timeline and cuts with our congressional champions, as well as those at the highest levels of the Department of Health and Human Services (HHS). We are urgently seeking a delay in the RO Model’s implementation date of January 1, 2021, so that practices have more time to prepare for implementation. This will also allow for additional time to address the flaws in the payment methodology, which, as they currently stand, equate to a series of cuts on radiation oncology services.

As we enter the last quarter of 2020, a year that has been fraught with tragedy, we are bracing ourselves for further struggles in 2021, with serious potential for more financial instability.  Whether your practice is in or out of the RO Model, Congress needs to hear your voice about the direct impact of these flawed policies. Go to https://www.astro.org/Advocacy/Become-an-Advocate and join the fight for the future of radiation oncology.

Posted: October 19, 2020 | 1 comments

ASTRO Resources Promote Correct Coding, a Key Element for Successful Practice Management

By Corbin Johnson, MD, CUAC chair, and Nikhil Thaker, MD, CUAC vice-chair

As radiation oncology heads into 2020, are you worried about whether your practice has its coding compliance in order and is up to speed on new coding rules?  ASTRO, the authority on radiation oncology coding, is rolling out an updated ASTRO Radiation Oncology Coding Resource and hosting a Coding and Coverage Seminar to help practices get off to the right start in the new year.

ASTRO’s Code Utilization and Application Committee (CUAC) works throughout the year to ensure that the radiation oncology (RO) community has access to comprehensive tools that assist with consistent application and interpretation of the Current Procedural Terminology (CPT®) code set most commonly used in RO. The CPT system, developed by the American Medical Association (AMA), is a highly technical process. New codes are developed, redefined and revalued every year for physicians and other qualified health care providers to report services provided in a universal manner to institutions, private and government payers, researchers and other interested parties. ASTRO actively provides input to the AMA and other groups that update the CPT coding system to ensure that CPT coding accurately reflects the clinical logic and level of effort that is required in RO.

Annual Coding and Coverage Seminar and Resource

CUAC’s primary responsibility is to understand the impact of these changes on coding for radiation oncology services. This includes providing membership with educational programs and materials that include the most recent and up-to-date coding guidance. One of the most popular educational programs that ASTRO offers to the RO community is the annual Coding and Coverage Seminar. This two-day seminar held at ASTRO headquarters provides a comprehensive overview of the many factors that affect the complex and ever-changing aspects of coding in clinical practice. The seminar is geared to make clinical coding easier to understand and applicable to those new to coding as well as for those with experience who are looking to hone their skills. This year’s seminar will take place on December 6 and 7 in Arlington, Virginia. Registration is currently open on the ASTRO website.

In addition to the seminar, CUAC also produces the ASTRO Radiation Oncology Coding Resource. The Coding Resource is designed as an orientation and reference document to assist physicians, their practice administrators and their staff to develop accurate coding and documentation procedures to support billing for RO services. The ASTRO Radiation Oncology Coding Resource is an essential coding reference for all radiation oncology practices, and ASTRO strongly encourages all coding/billing professionals to utilize this resource in their daily practice. This resource is updated twice a year to ensure that it reflects the most up-to-date information on CPT coding, rules and regulations related to radiation therapy. Coding and Coverage Seminar attendees will receive a copy of the updated Coding Resource as part of their registration.

Additional ASTRO coding resources

In addition to the comprehensive ASTRO Coding Resource and annual Coding and Coverage Seminar,   ASTRO provides the RO community with coding education through regularly updated coding FAQs, Coding Guidance Articles and Coding Updates on the ASTRO website. If ASTRO members have coding questions that are not answered through these various resources, or if further clarification on a nuanced topic is needed, they are encouraged to submit the question through the ASTRO Coding Question submission form. The questions submitted through the Coding Question submission form are processed through CUAC during their monthly meeting, and members are provided an answer to their questions via email. While providing individualized coding guidance to members, this question form also enables CUAC to keep track of frequently asked questions and topics that may have significant importance to the membership at large.

It's important to remember that correct coding encourages efficiency, reduces audit risk and claim rejections and facilitates efficient reimbursement. Additionally, accurate coding and proper supporting documentation demonstrate an understanding of the process and delivery of patient care. While correct coding reflects the process of care, it is vital to acknowledge that coding does not drive the process of care. Selection of codes should not be based on reimbursement but rather on the services provided by the physician that are considered medically necessary while caring for the patient. The physician of record is held responsible not only for all aspects of patient care but also for all codes and documentation submitted in his or her name. Arming yourself with a thorough understanding of these key elements and taking advantage of ASTRO’s educational resources can lead to successful practice management.

Corbin Johnson, MD is a radiation oncologist at Vanderbilt University Medical Center. Dr. Johnson currently serves as chair of ASTRO’s Code Utilization and Application Subcommittee in addition to playing a vital role as a member of ASTRO’s Code Development and Valuation Subcommittee.

Nikhil Thaker, MD, is a radiation oncologist with The Arizona Oncology Associates of Tucson and currently serves as vice-chair of ASTRO’s Code Utilization and Application Subcommittee, as well as serving on the Code Development and Valuation Subcommittee.

Posted: November 13, 2019 | 0 comments

Prior Authorization: Denial by delay

By Vivek Kavadi, MD

"Honestly, why do you need prior authorization for my cancer treatment? It is not elective!" This comment from one of our radiation patients represents the frustrations of many patients across the country. As vice-chair of the Payer Relations Subcommittee (PRC), I frequently receive complaints from ASTRO members about the negative effects that the prior authorization process has on their practice and their patients. In the recent ASTRO Prior Authorization Survey, an overwhelming majority of respondents reported that their patients experience delays in care. Nearly three quarters of these radiation oncologists also said that their patients regularly express concern over these delays.

I work in a cancer center where the radiation treatment area is in the same location as chemotherapy infusion. This provides for seamless coordination and patient convenience. However, when prior authorization for radiation is delayed, treatment with chemotherapy is also delayed. Combined modality treatment requires a lot of coordination. Radiation is daily and many infusions last several days. We often like to start both treatments on a Monday or Tuesday. Recently, treatment starts have become very unpredictable. It is not a rare circumstance where delays of one to two weeks occur due to prior authorization issues.

This issue remains at the forefront for radiation oncologists and the entire house of medicine, which led to ASTRO signing on to the Consensus Statement on Improving the Prior Authorization Process. The Consensus Statement outlines five areas for improvement for prior authorization programs. One area, the message of Transparency and Communication Regarding Prior Authorization, is extremely resonant in our current environment. Prior authorization requirements and rationale must be easily accessible to providers and patients. Perhaps most important, is the area discussing Continuity of Patient Care that emphasizes that prior authorization should not interrupt appropriate medical services, potentially causing harm and distress to patients.

My experiences are not unique; this issue affects us all. Last fall, more than 500 ASTRO members urged their members of Congress to sign the Roe-Bera Prior Authorization Letter, which called on the Centers for Medicare and Medicaid (CMS) to regulate Medicare Advantage plans’ use of prior authorization and ensure these requirements do not create barriers to care. PRC continues to engage with the American Medical Association and other stakeholders to reform prior authorization practices. ASTRO’s Government Relations team is working with our Hill champions to address prior authorization issues. We frequently provide updates in ASTROgrams and What’s Happening in Washington, so be sure to read those publications.

How has prior authorization impacted the way you practice? Let us know in the comments, or email  healthpolicy1@astro.org.

Posted: April 24, 2019 | 0 comments