Fw: HIV Facial Lipoatrophy- Follow up from Medicare

[Guest guest]

Read the email at the bottom first and work your way up.

Dear , Thank you for your email. You have highlighted some of the

major issues that I’m hearing directly from physicians and beneficiaries.

I will make an inquiry to the payment policy side of CMS regarding the price

set for the G code and try to find out if it will be revisited in the

future. As you know, the filler products are priced locally by the

Medicare contractors. I have learned that contractors are not consistent

and some have different pricing methodologies. For example, I don’t think

every contractor is requesting the invoice but it seems to me that these

contractors are at least seeing the real price of the products and hopefully

will not under reimburse. With all that said, I don’t have answers but will look into some

things. Please feel free to reach me again, perhaps I’ll have learned

more. Jo

Dear

Ms Baldwin:

I

hope this email finds you in good health. We have been exchanging emails

in the past as part of my advocacy work with facialwasting.org

I

am following up on codes used to get reimbursement for facial lipoatrophy

physician's fees. I am including in this email the comments from two well known

HIV physicians who do a lot of good work for the community to reconstruct faces

affected by HIV lipoatrophy. Can you please help us understand the issue with

the low reimbursement amount and codes? Thanks so much!

From Dr

Gerald Pierone

http://www.thebody.com/Forums/AIDS/FacialWasting/Current/Q211108.html?ic=700101

From

Dr Doug Mest:

Hi

Yes, VERY

true. Our good friends at the CMS get to decide what a service is worth. This

is why I was so adamant about a correct code being needed to truly describe the

amount of work being done. So instead of 11954 which already under paid around

150$ they created their own code G0429 that basically pays at a regular office

visit rate of $110. Now subtract the 20% and you get something around $85 per

treatment. Hopefully you are able to collect the copay but this barely covers

the cost of the billing service.

AND the worst

part of all of this is that now that it is a covered service, Medicare gets to

dictate the maximum amount you can charge EVEN IF YOU DECIDE NOT TO PARTICIPATE

IN MEDICARE. Meaning, you cant even balance bill patients legally even if they

are willing to pay. The maximum charge ever is around $126. And of course as

Medicare goes, so now will the regular insurance companies.

Also, they

have created new codes for the actual product but so far have not reimbursed me

since they want individual invoices so I cant even tell so far if I am losing

money on the product itself. Assuming that there may be a little increase for

stocking the material MAYBE we can see a little increase to the $100 per

treatment but I doubt it.

So Gerry is

right, the only way that this can be corrected is for a new code to actually be

created based on real time and effort it takes to treat and NOT based on some arbitrary

new code that they decide to use.

Can you

look into/ ask your contacts at CMS how/why they created G0429 and then based

it on a regular office visit and not on actual time/difficulty? Maybe they really dont know what

is involved in treating Facial LDS. A closer existing code is 21270.

Unfortunately, if this isnt corrected, the number of people who you fought for

to be able to get treated, wont be able to be helped.

Thanks for

asking

Doug

--

Greetings,

Vergel

FacialWasting.org