CORAR has worked closely with
Congress and the Centers for Medicare & Medicaid Services (CMS) in the past
to support Medicare beneficiary access to appropriate nuclear medicine/nuclear
cardiology procedures in all health care settings. We are pleased that for services reimbursed
under the Medicare physician fee schedule, Congress has long ensured that
physicians are reimbursed separately for all radiopharmaceuticals administered
in connection with nuclear medicine procedures.
In other words, a physician receives one payment for the office
procedure in addition to reimbursement for the radiopharmaceutical, which varies
based on the particular drug used. CMS
has followed Congressional directive in carrying out this policy. Medicare contractors establish the payment
basis for the radiopharmaceuticals, with some paying based on invoice cost and
others using a percentage of average wholesale price (AWP).
Unfortunately,
in the hospital outpatient setting, CMS has not followed the
Congressionally-mandated, statutory language to treat diagnostic
radiopharmaceuticals the same as other types of drugs (including therapeutic radiopharmaceuticals)
for payment purposes. Instead, since
2008 CMS has considered diagnostic radiopharmaceuticals to be supplies, and it
has packaged all diagnostic radiopharmaceutical costs into the hospital payment
for the procedure. In some cases, the
procedural payment does not even cover the costs of the diagnostic RP alone,
let alone adequately compensate the hospital for the cost of administering the
nuclear medicine test plus furnish the RP.
CORAR supports separate payment of all
diagnostic radiopharmaceuticals under OPPS and believes this policy will
support medical advancements and patient access to
innovative new diagnostic radiopharmaceuticals. Separate payment will
ensure adequate payment for important higher-cost, low-volume radiopharmaceuticals
where the current packaged payment policy does not cover even a fraction of the
radiopharmaceutical cost. In addition,
separate payment will support the White House national security initiative to
encourage a reliable, adequate and sustainable supply of medical radioisotopes
from non-Highly-Enriched Uranium (non-HEU) production sources, which is
imposing new costs into the production and use of RPs derived from non-HEU
sources.
Separate payment for all diagnostic
radiopharmaceuticals under OPPS will ensure that CMS provides appropriate
payment in the hospital outpatient setting that is consistent with other specified
covered outpatient drugs as well as provide a consistent payment policy for
diagnostic radiopharmaceuticals under both OPPS and the physician office
setting.