CMS Posts Decision of Non-coverage on Thermal Intradiscal Pain Therapy
Recently the Centers for Medicare & Medicaid Services (CMS) posted a non-coverage determination for IDET (Intradiscal Electrothermal Therapy), a non-surgical alternative treatment for discogenic low back pain. While a CPT code had been established, reimbursement had not. Ultimately the agency concluded that “there is insufficient evidence to conclude that thermal intradiscal procedures (TIPs) will improve health outcomes in the Medicare population with low back pain.”
Obtaining reimbursement codes and valuation for pain treatment is a continuing focus for AAPM on behalf of its members. As such, to help CMS better understand TIPs, including IDET, and the value of appropriate pain care to patients, AAPM participated in a joint response to CMS with AAPMR, ASA, ASIPP, ISIS, NASS and PASSOR. CMS will post its response to the letter and meeting with a final decision on reimbursement forthcoming.
Silent PPOs and Rental Networks
Most group practices are losing as much as 5-8% of their their reimbursement through illegal discounts taken by carriers who rents provider networks and agreements. When a physician contracts to join a health network, he or she agrees to accept a discounted rate in return for the network steering patients into his or her practice through a listing in the health plan’s directory. However, this discounted rate has been high-jacked through a deceptive market practice called a “silent PPO” or “rental network.” A silent PPO/rental network is neither insurance nor a health care payment plan offered by a health plan to its clients. Silent PPO/rental networks are not regulated and create a huge obstacle to heath care transparency.
A silent PPO/rental network generally takes no financial risk. The network “shops” around to find the lowest rates a physician has agreed to with any insurer, then “rents” that discounted rate to another entity without the physician’s knowledge or permission. Fourteen states have laws to prohibit these arrangements.
Patients also may suffer financially when the discount applied to their medical treatment is based inappropriately on the lowest contracted rate of a silent PPO/rental network. The patient may have to pay more toward the unpaid balance and incur higher coinsurance.
Silent PPO/rental networks provide no benefit to physician practices or their patients. Physicians may become wary of granting discounts under their existing contracts or are forced to increase their existing contracted rates to offset losses from these unethical manipulations.
Physicians should support legislation that will: 1) regulate how a physician’s contract rate is sold, leased, or shared among health plans, 2) ensure the physician’s right of action against anyone who improperly accesses their price discount and 3) encourage the state Department of Insurance to enforce current state insurance laws to alleviate this deceptive trade practice.
Compliants against a silent PPO or rental network should be filed with the state insurance commissioner’s office.
