Reimbursement of biotherapy: present status, future directions--perspectives of the office-based oncology nurse.
Economic forces are stimulating cost sensitivity and the need for clinical efficiency in medicine. The federal government has led the way with Medicare reform, and cost-containment efforts are evident in all health care payer programs. More and more, the office-based oncology nurse is involved in reimbursement issues as both a colleague and a patient advocate. Creative solutions to the challenges of reimbursement require knowledge of the issues, familiarity with patient-specific therapies, and recognition of unique cost and billing issues. Biologic agents frequently used in office-based oncology practice are easy targets for reimbursement denials because of regulations against their investigational status, "off-label" use, method of administration, and relatively high cost. Such agents include interferon, erythropoietin (EPO), granulocyte and granulocyte-macrophage colony-stimulating factors (G-CSF and GM-CSF, respectively), and interleukin-2 (IL-2). Reimbursement decisions are often characterized by inconsistency and uncertainty, and rulings are based not only on law, but also on interpretation. The need for clarification often opens a window for negotiation for the complex reimbursement issues associated with biotherapy. In addition to thoroughly determining cost and accurately assigning appropriate Current Procedural Terminology (CPT) codes, office-based oncology nurses can pursue various strategies to help their patients and practices obtain reimbursement of biotherapy. Chief among these is educating third-party payers on the appropriateness and necessity of newer treatment modalities. In individual cases, documentation of the scientific data, clinical outcomes, and cost benefits supporting a treatment decision almost always gains reimbursement.(ABSTRACT TRUNCATED AT 250 WORDS)
Xistris
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P.C. Bennett Cancer Center, Stamford, CT.
D003361:Cost Allocation; D016527:Drug Costs; D004345:Drug Industry; D015507:Drugs, Investigational / Q000191:economics / Q000627:therapeutic use; D005544:Forecasting; D006801:Humans; D007155:Immunologic Factors / Q000191:economics* / Q000627:therapeutic use; D007255:Information Services / Q000592:standards; D009369:Neoplasms / Q000191:economics / Q000451:nursing / Q000628:therapy*; D009818:Office Nursing; D009859:Oncology Nursing / Q000379:methods*; D012051:Reimbursement Mechanisms / Q000592:standards* / Q000639:trends; D014481:United States; D014486:United States Food and Drug Administration
D015507:Drugs, Investigational; D007155:Immunologic Factors