Question & Answer: Lupron by Jeffrey Kaufman, M.D., FACS

QUESTION

Dear Dr. Kaufman:

Thank you for your tremendous efforts in dealing with the Lupron repayment crises.

PRG Schultz has now embarked in other endeavors and have requested records with Mitomycin C instillations.

They have not requested the documentation supporting the use of Mitomycin C instillation, only the code for Mitoymycin C. Of course, they made it difficult to identify the patient, by not including their name, but only stating their Medicare number and the date of service.

Should I send additional information, from another date of service, which was not requested, that supported the use for Mitocycin C rather than BCG, the lower cost drug? There was no charge for an EM service on the date of instillation, only the charge for instillation and Mitomycin C. The documentation is for 40 mg versus 20 mg.

I thank you again for your great efforts in dealing with Lupron. It appears that PRG Shultz may go after all drug treatments for the lowest cost payment, which should create a greater uproar for medical specialties that administer parenteral medications.

After reading through all the communications, PRG Schultz expects to collect their monies from direct re-payments from doctors or from withholds from future Medicare Payments. Are non participating physicians receiving repayment requests? Are retired physicians receiving repayment requests? If they are, will PRG Schultz use a collection agency to collect money due from those physician categories?

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ANSWER

Several issues are pertinent here. First, be sure the claim date in question falls within the 4 year scope allowed to them (determined by the date the claim was paid). Second, I have already complained to CMS and PPAC that the letters are vague and do not include enough information to allow you to know what to submit, especially if they don't make it clear what particular aspect of your care is being investigated. This holds (obviously) when they don't include the patient name but only refer to the claim by their internal code. We have already gone round with them on this and they are SUPPOSED to refer to the patient by name and the claim by date. Next, in most cases where records are requested, they are doing a "complex" review to confirm that the care was delivered, was reasonable and necessary, was billed and paid for correctly and that all policies were adhered to. I would submit all related documents that support the indication (such as pathology reports, consults, previous records showing that this particular treatment is necessary (such as previous failure to respond to BCG or something about their situation that specifically warrants mitomicin, etc) even if it is not specifically requested or pertains to another date of service. Remember, these charts are reviewed by nursing, not doctors and they may have no idea about proper treatments beyond what they read in some printed policy. If appropriate and necessary, include a separate letter translating any abbreviations you use, explaining the background on this case (such as why you chose mitomicin) and why this disease warranted treatment in the first place. Finally, if there is a specific policy on an issue for which records are requested, try to respond directly to what you suspect they are questioning to head off trouble prophylactically. HOWEVER, realize that the general policy that raised questions about LHRH agonists specifically relates to Least Costly Alternative (not least costly drug). There is no policy that suggests mitomycin and BCG are alternatives. They are different drugs used in different situations. While the LCA policy is based on the concept that Medicare is only charged with paying for reasonable and necessary treatment (and they don't consider more expensive alternatives either), they crux of any argument over LCA is whether the agents compared are truly alternatives. You can't argue that radical cystectomy and intravesical instillations are reasonable alternatives even though both treat bladder cancer. Similarly, BCG and mitomycin are used differently, have different side effects and therapeutic outcomes. If you had any reason at all for your choice of mitomycin (and I assume you had some basis for choosing it regardless whether some nurse agrees with your clinical judgement), you have the right and responsibility to treat as your training and experience indicate. They cannot deny you payment for mitomycin based on the LCA policy. If they try, let me know and I will help you draft an appeal and take the decision to the highest levels since it exceeds their authoritity to apply policies. I would have to research the BCG policy but I am fairly certain no one could interpret these two drugs as alternatives in the was we have considered the term previously. The RAC would be breaking entirely new ground here and would be challenged.

If I am correct that they simply can't review this case under the least costly alternative policy umbrella, then they must be searching to confirm that the drug was administered consistent with policy (proper indication, doctor in attendance, dose in chart confirms what was billed, medical literature supports use, chart fully documents what was done,etc.). Review your records carefully before sending them and include a letter of explanation or support or justification if necessary and include all data you think a nurse would need to understand what you did, why you did it and to believe you did it correctly and deserve to be paid.

Next issue was that the RAC doesn't collect money if the appeal is won. And, the carrier NHIC doesn't withhold money during the time an appeal is considered althought, if you lose the appeal, you will owe interest from the time the money was first due. However, this is all dependent on the fact that they feel money was paid incorrectly and demand recoupment, a decision I would hope doesn't occur. I hope that answers your questins. Please follow up and let me know how this turns out. Contact me for any other questions.

Jeffrey Kaufman, M.D.
CUA

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