Did you know there are several prescriptions in the US that cost more than $100,000 per year? The ten most expensive prescription drugs currently approved by the FDA are:
1. Solaris: $409,500 annually. The drug, created by Alexion Pharmaceuticals, treats hemoglobinuria – a rare blood disease. Some 8,000 Americans are treated for this, resulting in more than $500 million in sales annually.
2. Elaprase: $375,000 annually. Prescribed to treat an enzyme deficiency (iduronate sulfatase) costs $4,215 per vial. Some 500 Americans are treated annually for Hunter syndrome, resulting ing more than $350 million in annual sales.
3. Naglazyme: $365,000 annually. This human enzyme medication is used to treat a rare genetic metabolic condition: Maroteaux-Lamy syndrome. Untreated, the illness causes mental retardation in children. The drug is also given for increased range of motion and pain management.
4. Cinryze: $350,000 annually. Prescribed to treat a C1 inhibiotr protein found in hereditary angioedema. The synthetic protein is a CI esterase inhibitor, manufactured by Viropharma. The disease is rare, yet the company reports $350 million in annual sales.
5. Folotyn: $320,000 annually. The cancer drug helps those with T-cell lymphoma. The short-course treatment is typically not given annually, but in $30,000 per month increments.
6. ACTH: $161,000 per average treatment. Prescribed to aid seizures in infants, the drug costs $23,000 per vial, with a typical treatment being 6-7 vials. The drug is not currently approved to treat infantile spasms, although it is also often prescribed off label – thereby not covered by insurance.
7. Myozyme: $100,000 (children), $300,000 (adults) annually. The treatment for Pompe disease allows suffers to typically stay off of respirators and continue to speak and walk. The disease and drug were featured in the movie Extraordinary Measures. Pompe disease disables the heart and skeletal muscles, leaving those without access to the drug immobile.
8. Arcalyst: $250,000 annually. Given to those who suffer from genetic immune system diseases, including Familiar Cold Auto-inflammatory Sndrome and Muckle-Wells Syndrome. The drug has also shown to help reduce incidence of gout.
9: Ceredase/Cerezyme: $150,000 annually. The expense of this drug to treat Gaucher disease – where the body pools fat in muscles and other areas due to an enzyme deficiency – is expensive due to supplies required. The drug is made in part from human placentas, which replace the missing enzyme. The drug results in more than $1 billion in annual sales.
10. Fabrazyme: $200,000 annually. Created to treat Fabry disease, an enzyme deficiency-related illness, Fabrazyme provides the ability for patients to metabolize lipids.
The Obama administration announced a new Health and Human Services task force for uncovering Medicaid waste and fraud. This comes just one week after 91 people, including physicians and nurses, were arrested nationally for a $295 million dollar Medicare scam.
When was the last time you reviewed your billing practices? If auditors arrived at your doorstep today, would your billing and administrative team know how to respond? Are your charts in order? Are your finances transparent?
Boost Medical works with pain practices nationally to ensure when such officials arrive, our clients are more than prepared. One of our five tiers of service is medical billing. We have seen great success in the practices we manage in examining billing compliance. We review current billing policies, implement updated procedures, train staff accordingly, monitor monthly financial reports and keep owner-physician up to date with federal and state law.
Our billing specialists are also experts at reviewing and collecting on accounts receivable.
Originally published in Pain Medicine News; reprinted with permission
—Tory McJunkin, MD, Paul Lynch, MD, Sagar Gondalia, and Ryan Tapscott, PhD
Dear Arizona Pain Specialists,
I have a small pain medicine practice, but we’re expanding fast. Our model for patient care relies heavily on the work of nurse practitioners and physician assistants. I recently read about a Medicare billing practice known as “incident-to” billing, but the guidelines seem complicated. What do you know about “incident-to” billing?
Dear Incidentally Confused,
Congratulations on your success and growing practice. There is indeed a Medicare guideline known as incident-to billing. This is when a qualified mid-level provider (MLP; physician assistant [PA], nurse practitioner [NP], clinical nurse specialist, certified nurse midwife, clinical psychologist, clinical social worker, physical therapist, speech-language pathologist or occupational therapist) provides patient care, but bills the visit under the physician’s National Provider Identifier (NPI) rather than his or her own. Medicare pays MLPs at 85% of the physician’s fee schedule. But when billed as incident-to, Medicare pays at 100% of the physician’s fee schedule because the visit falls under the physician’s NPI. The Medicare criteria for incident-to billing are not well understood by most physicians, so we will try to clear up any confusion.
According to Medicare, there are nine criteria that must be met to qualify for incident-to billing:
The patient treated by auxiliary staff must be an established patient of some physician and cannot be a new patient.
The physician must have seen the patient first and initiated the plan of care, including subsequent services by auxiliary staff.
It is recommended that the physician inform the patient that a qualified practitioner will be caring for the patient under the physician’s direction and monitoring.
Services provided and billed incident-to must be for office or home services and ordered by a physician. Incident-to billing does not apply to hospital inpatient, comprehensive outpatient rehabilitation facility or rehabilitation agency services. (Note, however, that incident-to billing does apply to outpatient hospital clinics and outpatient skilled nursing facility services.)
The physician must be present on site, either in the office suite or in the patient’s home, during the time that the patient is seen and immediately available to provide assistance and direction when the qualified practitioner is performing services.
The physician must remain actively involved in the patient’s care and must periodically see the patient for the ongoing disease or illness. It is also recommended that the physician review the qualified practitioner’s chart notes in order to monitor treatment progress.
Incident-to rules do not apply if there is a new illness or problem for which the physician has not previously seen the patient and there is not an established plan of care.
Billing must be done under the billing number of the physician who is actually on site providing supervisory services rather than the physician who initiated and provides ongoing monitoring of the patient’s care.
Admittedly, this seems cumbersome and overwhelming. However, Arizona Pain Specialists has developed a set of easy questions to ask a patient at each visit to accurately and quickly determine if a visit is eligible for incident-to billing status.
Before revealing these questions, two terms must be defined: the rendering provider and the billing provider. The practitioner who renders service is the rendering provider. The practitioner under whom the service is billed is the billing provider. In a practice unconcerned with incident-to billing, these two would be the same. With incident-to billing, however, only three possible situations allow for incident-to billing:
The physician is both the billing and rendering provider.
The MLP is both the billing and rendering provider.
The physician is the billing provider and the MLP is the rendering provider. This is the only situation in which a visit can be billed incident-to the physician.
Arizona Pain Specialists has created a logic tree based on billing office visits that automatically determines rendering provider and billing provider (and implicitly incident-to billing). Because the office visit is always billed, regardless of other services performed during the visit, this logic tree is attached to the sections indicated on the superbill associated with the office visit codes (e.g., 99203-99205 and 99211-99215).
On the top of all clinic superbills is a section for both new patient office visits and established patient office visits. This organization creates an immediate dichotomy between the two and helps simplify the process of determining the billing and rendering provider. The new patient section of the superbill definitively establishes that the visit cannot be billed incident-to because a physician has not established a plan of care (Figure 1). Either the MLP is both the billing and rendering provider, or, if the physician saw the patient, he or she is both the billing and rendering provider. Notice how this is explicitly indicated as a reminder to the provider while he or she completes the superbill.
Determining the rendering and billing provider for an established patient can be more complex as this is where incident-to billing is possible. Nevertheless, with a few easy questions built right into the superbill this can be deciphered without any headaches.
Notice in the established patient form (Figure 2) there are separate boxes for the rendering and billing provider, an indicator to the provider that it is possible for the two to differ (whereas with new patients the two must always be the same). If the physician saw the patient, he or she is the rendering and billing provider. If not, two possibilities remain: Either the MLP is both the rendering and billing provider, or the MLP is the rendering provider and the physician is the billing provider.
There are three questions listed below the initial query that will help determine which case is correct. If, and only if, all three questions are answered “yes,” can the visit be billed incident-to the MLP as the rendering provider and the physician as the billing provider. If “no” is the answer to any of the questions, then the MLP must be both the rendering and billing provider. This scenario is further detailed in a single logic tree and flowchart that follows:
Is the patient new or established?
Was the patient seen and examined by a physician?
If yes, the physician is both the billing and rendering provider. It is important to note that when billing incident-to the physician, the visit should be billed under the on-site supervising physician, even if this is not the same physician who established the plan of care.
If no, was the current plan of care established by a physician? Was the plan of care followed without change? Is there an on-site supervising physician?
If “no” is the answer to any of these questions, the MLP is both the billing and rendering provider. If all of these questions are answered “yes,” the MLP is the rendering provider and the on-site supervising physician is the billing provider.
These are the tools you will need to determine if a visit should be billed incident-to. We have included several examples of hypothetical patients here to further illustrate how to bill properly. These sample patients are not real people, and their names are fictitious. Many insurance companies handle billing under MLPs differently from Medicare and some don’t recognize incident-to billing at all. Before billing these insurance companies, make sure you understand how each insurance company wants you to bill with MLPs.
Scenario 1: Howard Rorek arrived at our pain clinic with complaints of low back pain. He was seen initially by an NP, but a physician was consulted and came into the room to perform an evaluation on him. The physician then determined the course of treatment for Mr. Rorek. In this case, the physician saw the patient, and thus he should be both the rendering and billing provider.
Scenario 2: Domineek Frankon was a new patient who had been suffering from severe pain in her left leg. There was no physician on the premises during Ms. Frankon’s first visit and she was seen by a PA who determined her plan of care. The patient never saw a physician and so the PA was both the rendering and billing provider.
Scenario 3: Francysko D’Ankoniya was a new patient seeking treatment for foot and ankle pain in both of his legs. He was seen by an NP. There was an on-site physician and the NP briefly consulted the physician outside the exam room about Mr. D’Ankoniya’s plan of care. The physician did not, however, enter the room or perform an examination on the patient. Because the physician did not see the patient, the NP is both the billing and rendering provider.
Scenario 1: Dagnee Taggert was a patient who had been on a continued plan of care for three months. She recently had a successful lumbar radiofrequency ablation procedure and was being seen in follow-up to that procedure. A physician saw Ms. Taggert, so the physician is both the billing and rendering provider, and the patient would not be eligible for incident-to billing.
Scenario 2: Jon Gahlt was seen for an initial visit two weeks ago and then came in for his first follow-up appointment. He did not see a physician at his initial visit, and only saw the PA at today’s visit. There was an on-site supervising physician present. The visit should be billed with the PA being the rendering and billing provider because the physician did not establish the patient’s plan of care. Had the on-site physician seen the patient that day, and established a new or different plan of care, the visit would be billed with the physician as billing and rendering provider, and the patient would be eligible for incident-to billing for future visits.
Scenario 3: Peetur Qiteeng met with a physician in his first office visit and has been working on slowly decreasing the amount of medication he is on. He came in for a follow-up appointment to assess his progress. During this visit he saw an NP. Additionally, the on-site supervising physician was not the original doctor who examined Mr. Qiteeng. Nonetheless, because there was a supervising physician present, and the patient’s plan of care was both established by a physician and the MLP followed that plan of care without change, the visit should be billed incident-to the doctor: The MLP is the rendering provider and the on-site supervising physician is the billing provider. In this case, the patient would be eligible for incident-to billing for future visits.
Scenario 4: Gayle Wyenend first met with a physician who established a plan of care. To help with his back pain, the plan involved double diagnostic medial branch blocks. Mr. Wyenend returned to the clinic and saw an NP. Mr. Wyenend had a fall and complained of new pain in his left arm. The physician was present, but did not visit or examine the patient about his new complaint. Because a new pain complaint was presented and a new plan of care was established, the visit could not be billed incident-to. The MLP was both the billing and rendering provider so the patient is not eligible for incident-to billing.
Drs. McJunkin and Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations, seven pain physicians, 10 midlevel providers, three chiropractors, on-site research and behavioral therapy. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country. For more information, visit ArizonaPain.com and BoostMedical.com.