Don't Watch Your Isotope Payments Decay - Fight Back

Use the rarity of your specialty as a bargaining chip to bring payers in line
If your practice provides radiopharmaceutical therapy in a non-hospital setting, chances are you're one-of-a-kind in your area - and that's what payers don't like to hear.
 
You have nothing to lose by negotiating with payers for a decent payment rate on radiopharmaceutical therapy, says Barbara Waldinger, practice manager at Endocrinology Nuclear Medicine in San Antonio. Waldinger has encountered a drop in payment from several carriers during her years billing for radiopharmaceutical therapy, but she has successfully negotiated better rates or else told payers to take a hike.
 
"In fact, we cancelled an HMO we had because they didn't want to pay us fairly ... and now they're calling us and asking to negotiate a contract because patients in the area want to use our services," Waldinger says.
 
Be on the lookout: Payers frequently look for ways to reduce the amount they pay you for A9516 (Supply of radiopharmaceutical diagnostic imaging agent, I-123 sodium iodide capsule, per 100 uci) and A9517 (Supply of radiopharmaceutical therapeutic imaging agent, I-131 sodium iodide capsule, per mci) because these isotopes are so expensive. For example, Waldinger had to fight with one payer who claimed that A9517 is for up to 5 units of I-131 - even though the code descriptor clearly states "per mci." The payer essentially wanted to reimburse only one-fifth of Waldinger's deserved payment.
 
Another insurance company suddenly starting paying $12.50 per unit of A9517 when it had been paying $136 per unit, Waldinger says. If a carrier tries to pull something like this, tell them, "We don't have to see your patients, and we won't," she says. If the payer wants its patients to have treatment, it will have to come around.

- Published on 2004-11-21