Overview of Spectrum Health Financial Feasibility Principal Investigator TrainingAugust 2010
Objective The Goals of Today’s Training
Agenda • Outline the Feasibility Coverage Analysis (FCA) • Explain CMS Guidance on Reimbursement for Clinical Trials • Describe Medicare’s Approval Process for Investigational Device Trials • Describe Spectrum Health’s Plan for Compliance with Medicare Regulations for Clinical Research
The Feasibility Coverage Analysis (FCA) • A feasibility coverage analysis is a systematic review of protocol-related documents to determine if all the patient care costs in a study are covered by the study sponsor, other funding sources, or qualify for reimbursement by third party payers.
Three Benefits of Conducting a FCA • Early detection of items and services not covered by Medicare • Develop a spreadsheet of all the patient care costs in the study. • Determine if the trial qualifies for reimbursement under Medicare’s criteria. • Identify costs not covered by insurance or the study sponsor. • Development of a tool to ensure compliant claims processing • Identify the claims to be split before billing. • Identify the services that need research specific codes and/or modifiers. • Identify the charges to be submitted to the study sponsor.
Three Benefits of Conducting a FCA, Cont’d • Medicare’s expanded coverage of clinical trials means increased opportunities for reimbursement of the following: • Services typically provided to patients with the disease under study (e.g. conventional care). • Services provided to administer a drug, implant a medical device, or deliver a service. • Clinically appropriate monitoring of the drug, medical device or service. • Prevention, diagnosis, and/or treatment of complications.
Environment for Research Compliance Regulatory climate for clinical research billing compliance • CMS created an integrated data repository for Medicare, Medicaid, and liability claims data to be used in identifying improper payments1. • A standardized approach to billing for Medicare, Medicaid, and commercial payers is preferred • Double-billing must be prevented • Health care reform legislation requires the following: • Commercial payers to cover routine care for some research2. • Increased funding for Medicaid fraud and abuse control 1 CMS Integrated Data Repository (IDR) Overview, www.cms.gov/IDR/ . 2 Section 10103 of the Patient Protection and Affordable Care Act (PPACA).
Example FCA Grid – Outpatient Drug Study These will be billed to the third party payer. This will be billed to the research account and potentially the sponsor .
Example FCA Grid - Inpatient Device Study This will be billed to the third party payer. These costs will not be billed. These will be billed to the third party payer as a part of the DRG.
DRAFT - Confidential - Attorney Client Privileged - Attorney Work Product Completing the FCA Spectrum Health requires an FCA for all new studies with patient care costs (excluding chart reviews and retrospective studies). IRB approvals will be held until the Feasibility Review is completed.
Drafting the FCA • Steps • Study Coordinator (SC) documents the study identifying information • SC drafts the Feasibility Grid using the protocol schedule of events • SC consults the Principal Investigator to identify services that are solely for research purposes versus those that are for one of the following reasons: • Medical Management of the patient • Prevention, diagnosis, or treatment of complications • Administration of an investigational item or service • SC assigns a preliminary designation to each service using the options on the next page • SC completes the Device or Drug/Procedure study tabs, as appropriate • PI and SC submit the analysis to email@example.com and firstname.lastname@example.org.
Potential Designations for the FCA Please note: There may be instances when using more than one code is appropriate. For example, with a CT scan, there is a professional and technical fee associated with it. So it would have at least two codes if the scan was completed at a Spectrum Hospital.
RA Office Review of the FCA Once the FCA is completed by the research team, the RA Office completes the following steps: • Reviews the FCA for completeness and accuracy • Validates qualifying status of the study • Verifies CPT/HCPCS codes for items and services, where relevant • Reviews Medicare guidance on reimbursement for routine items and services • Drafts the budget • Provides feedback to the research team • Approves the FCA
Comprehension Question 1 • Which statement is NOT a benefit of the FCA? • Early detection of items and services not covered by Medicare. • Development of a tool to ensure compliant claims processing. • Identifying increased opportunities for reimbursement of complications related services. • Identifying research participants.
Comprehension Question 2 • Which statement is NOT true? • Spectrum Health requires an FCA on all existing studies. • Spectrum Health requires an FCA on all new studies. • Feasibility approval is needed before the IRB Approval letter can be released. • The Principal Investigator identifies the services that are solely for research purposes versus those that are for the medical management of the patient.
Medicare Guidance on Reimbursement of Routine Costs in Clinical Research
Coverage of Investigational Device Trials • Spectrum submits documentation to Medicare’s designated contractor for approval to bill services “incident to” a device as required by local and national regulations. • Devices that may be covered under Medicare include the following categories: • Devices approved by the FDA through the Pre-Market Approval (PMA) process; • Devices cleared by the FDA through the 510(k) process; • FDA-approved IDE Category B devices; and • Hospital Institutional Review Board (IRB) approved IDE devices • Category A devices are not reimbursed by Medicare Source: Medicare Benefit Policy Manual Chapter 14 – Medical Devices
Coverage of Drug Trials • Medicare implemented the Clinical Trial Policy (CTP) in 2000 to address coverage of the “routine costs” that were previously uncovered. ““. . . Medicare covers the routine costs of qualifying clinical trials...as well as reasonable and necessary items and services used to diagnose and treat complications arising from participation in all clinical trials. All other Medicare rules apply...”* • The FCA helps to analyze a study using Medicare’s “qualifying” criteria described in the next slide. • The FCA assists in identifying the “routine costs” described in the CTP. Source: CMS Clinical Trial Policy, updated 2007
CMS Clinical Trial PolicyQualifying Clinical Trials (QCT) Qualifying trials meet all four of Medicare’s criteria for reimbursement of routine care costs. Source: Clinical Trial Policy
CMS Clinical Trial Policy “Deemed” Trial (continued) • Trials that are automatically “deemed” to meet the seven desirable characteristics are • Spectrum’s IND Exemption Policy: • Industry-sponsored research will have a determination in advance of Spectrum feasibility review. • Investigator-initiated research will get a determination from the IRB Source: Clinical Trial Policy
Trials that Do Not Qualify for Medicare Reimbursement of Routine Costs These studies are not feasible unless one of the following criteria are met: • The study sponsor is covering all of the patient care costs (PCC) • The PCCs are minimal • An alternative source of funding is identified.
Routine Costs of Qualifying Clinical Trials CMS has defined ‘routine costs’ as the following:
Medicare – General Exclusions from Coverage The following is a list of general exclusions from coverage as these items would not typically be covered outside of a clinical trial: • Routine physical checkups • Eyeglasses or contact lenses • Eye examinations • Hearing Aids • Immunizations (some exceptions) • Orthopedic Shoes • Custodial Care • Cosmetic Surgery • Dental Services • Any Services that are not Reasonable and Necessary • Others Source: 42 CFR 411.15
Medicare Advantage Patients Medicare requires routine care for research related visits (except IDE cat A & B trials) to go through the traditional plans, not Medicare Advantage. • Deductibles will be waived • Fee-for-service Medicare contractorswill make payment according to the traditional Medicare rules. • Patients are responsible for co-payments under the traditional Medicare rules.
Glossary of Medicare Codes for Research Medicare’s Clinical Trial Policy and Investigational Medical Device Regulations require specific codes and modifiers be added to claims for processing and segregation of research charges. The following is a glossary of the current Medicare requirements:
Medicare Claims Processing Requirements • Medical Records must include: • Trial name; • Trial sponsor; and • Sponsor-assigned protocol number. • Claims for routine costs to the Part B Contractor must include: • Q0/Q1 modifiers; • ICD-9 diagnosis code V70.7 (as secondary diagnosis); • Revenue Code 0256 – Experimental Drugs; and • Revenue Code 0624 – FDA Investigational Devices. • Claims for routine costs to the Part A Contractor must include: • All the Part B contractor codes (modifiers are for outpatient claims only); and • Condition Code 30.
Comprehension Question 3 • Which type of device is NOT covered by Medicare? • Devices approved by the FDA through the Pre-Market Approval (PMA) process; • Devices cleared by the FDA through the 510(k) process; • FDA-approved IDE Category A devices; • FDA-approved IDE Category B devices; and • Hospital Institutional Review Board (IRB) approved IDE devices
Comprehension Question 4 • Qualifying Clinical Trials must meet which of the following criteria? • The investigational item or service is a member of a Medicare benefit category. • The trial has therapeutic intent. • The trial enrolls patients with diagnosed disease. • The trial is “deemed” to meet the 7 desirable characteristics. • All of the above.
Comprehension Question 5 • Trials that are automatically deemed to meet the 7 Desirable characteristics may include which of the following? • Funded by NIH, CDC, AHRQ, HCFA (CMS), DOD, and VA • Supported by centers or cooperative groups that are funded by the NIH, CDC, AHRQ, HCFA, DOD and VA • Conducted under an investigational new drug application (IND) reviewed by the FDA • Drug trials that are exempt from having an IND • A, B, & C Only • All of the above.
Comprehension Question 6 • Medicare defines routine costs to exclude which of the following? • Items and services required solely for the provision of the investigational item or service. • Monitoring of the effects of the investigational item or service. • Prevention, diagnosis, or treatment of complications. • The investigational item or service, itself; unless otherwise covered outside of the clinical trial. • All of the above.
Implementation of the Financial Feasibility Review Process
Roll-Out Schedule • Completion of the FCA will be required for all new studies submitted on or after October 1, 2010. • Billing Grids will be implemented as they are created for new studies. • An announcement regarding implementation for existing studies will occur on or before January 1, 2011.