Shared data, changes to CAP bring challenges to 2006

February 1, 2006

Ray Painter, MD As we move into the new year, urologists face three major issues affecting reimbursement: the need for improved data, a change in the Competitive Acquisition Program (CAP), and the inclusion of Medicare Part A in the average sales price/least costly alternative (ASP/LCA) payment process for Part B drugs.

'Data are gold'

The new Golden Rule is, "He who has the data has the gold."

As we move forward in the information era, having a complete data set on all aspects of our business is becoming more and more crucial. Good practice management reports are mandatory for running an efficient practice. We know the value of having a complete set of payment rules for a particular payer. We also know that such a set of rules is difficult, if not impossible, to find at times.

We're being introduced to the fact that good charge and payment data are crucial to proving the quality of our practice as more and more payers look at the charge data to determine if treatment criteria have been met or if certain services have been provided that have been determined to be of value in a particular disease process. This is being labeled "transparency of provider care" by some payers and "pay for performance" by others.

How would you like to know all payer rules prior to billing for a service, the exact amount you will be paid by an insurance company prior to providing the service, the outcome of precise electronic tracking of your claims to counteract any notion that a payer did not receive the claim, payment by payers to other urologists in your geographic area prior to signing the contract, and whether a payer is paying other providers for services for which they deny payment to you?

Consider the value of a report card or a compliance report on each payer that you have the option to contract with. How about a complete, clear-cut, automated analysis of each EOB as it is received or a verifiable record of services provided that could be used to challenge payer interpretations?

All these data sets are potentially achievable with currently available technology, data collection capabilities, and database interpretation software. Correlation of data with appropriate interpretation gives you additional valuable information.

Similarly, would you like to have information that benchmarks your practice against other, similar practices, determines how you are paid compared with others, and determines the efficiency of your practice compared with others? The list goes on and on. Again, this is achievable and it is something we should work together to develop.

Many of us have excellent practice management systems, and enjoy many of the data sets mentioned here. We also have benchmarking data from surveys through our various organizations; however, the next level of information that is truly needed to run an efficient and affective practice is shared data.

We need a comprehensive, urology-specific payer database. A complete data set controlled by urologists could be used to not only develop good treatment criteria, but also to counteract data that are incomplete and controlled by payers who have a significant interest in their financial impact. Physicians, concerned with quality of care, need control of these data sets to have a meaningful impact on quality of care determinations.

Shared data provided to you from a third-party vendor, without names, are legal under Federal Trade Commission regulations.

The CAP is on

The Medicare CAP is on, although it's a little crooked and certainly not watertight.