HCFA: Medicare will pay for multiple, same-day consults

Physicians turned to Congress for relief from Medicare payment rules they thought prohibited payment for some patient visits and undermined full-service oncology clinics.

By LaCrisha Butler, amednews staff. Feb. 28, 2000.

Washington -- Several physicians in Pinehurst, N.C., were seeking to begin a multidisciplinary breast cancer clinic so that newly diagnosed patients could visit one location for an initial consultation and discuss with all the physicians involved -- surgeons, oncologists, radiation oncologists and plastic surgeons -- the various treatment options available.

Their biggest obstacle: Medicare carriers would not pay for multiple consultations for the same patient on the same day -- or so they thought. The physicians, led by Michael Rowland, MD, a general surgeon at the Pinehurst Surgical Clinic, turned to Congress and asked Sen. Jesse Helms (R, N.C.) for help.

"In case of oncological care, such coverage rules are outdated and inappropriate, since cancer patients inherently require multi-modality care," Helms and Sen. Connie Mack (R, Fla.) wrote to Nancy-Ann DeParle, administrator of the Health Care Financing Administration.

As a result of current coverage rules, "patients are often required to make several appointments over several days in order to obtain all the necessary consultations from all the various specialists."

In the case of the proposed Pinehurst clinic, where patients were expected to come from all across the region, such stringent payment rules would have forced patients to stay overnight several days in order to see the required specialists or to make three different trips to the clinic.

The physicians sought a "special exemption for medical and surgical specialists that provide care to Medicare beneficiaries in multidisciplinary cancer clinics," according to the letter, signed by 11 senators.

Government go-ahead

DeParle gave a green light to the physicians and the rest of the cancer community, which had been grappling with this issue for some time.

"Medicare's payment policy does allow for such multiple consultations in certain circumstances," she wrote. But the services have to be medically necessary, she emphasized.

"This is a major victory," Dr. Rowland said. "More and more now, [cancer patients] are treated with multiple therapy. Years ago, it was not as common to have coordinated multidisciplinary care. It is now becoming the norm.

"I think we have the ability now to inform the doctors: 'Yes, if you participate in this program, you are now going to get reimbursed,' " he added.

The clarification is good news, said Christian Downs, director of provider economics and public policy at the Assn. of Community Cancer Centers.

"In the past, some of our members have had problems with this," he said. "It is critical, especially, for cancer patients to be able to come to a cancer center and to be able to receive their services all at one time."

He remained cautious, though, about whether HCFA policy will be made clear to carriers.

In her letter, DeParle explained Medicare policy on two types of services: those billed as consultations, which are reimbursed at a higher level than office visits, and those not billed as consultations but provided concurrently.

On consultations, DeParle wrote: "Medicare policy does not stipulate a frequency limit on the number of consultations provided by physicians for a single patient on any given day. The determining factor is the medical necessity of the services provided."

For services not billed as consultations but provided concurrently, "payment may be made for the services of more than one physician during a given time when such services are considered by the Medicare Part B carrier to be reasonable and necessary," she wrote. Each physician must play an active role in the patient's treatment, and their services must not be duplicative in order for the care to be deemed reasonable and necessary.

"We agree it would not be unusual for concurrent care to be performed by physicians in different specialties such as within a multidisciplinary cancer clinic," DeParle wrote.

When deciding if services are reasonable and needed, carriers should consider the physicians' specialties, the patient's condition and the medical necessity of the particular services, she said.