Clinical Research Billing Basics & How to Develop a Coverage Analysis

Transcription

1 Clinical Research Billing Basics & How to Develop a Coverage Analysis Julie Colasacco & Michael C. Roach Presented at Virginia Commonwealth University August 29, N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com

2 Goals Raise Awareness Teach knowledge transfer 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 2

3 Important Terms & Acronyms Clinical Research Billing CRB Medicare Clinical Trial Policy CTP Qualifying Clinical Trial QCT Centers for Medicare & Medicaid Services CMS 3

4 Overview 1. Regulatory risks of clinical research billing non-compliance 2. The importance of a Coverage Analysis (CA) for compliance 3. An overview of Medicare rules for billing during clinical research studies 4. The basics of billing for research team members 5. How the budget structure influences what can be billed to insurance 6. How the language of the Informed Consent Form influences what can be billed to insurance 7. What does Medicare mean by a qualifying clinical trial? 8. What does Medicare mean by routine costs? 9. The importance of the research coordinator in ensuring clinical research billing is compliant 10. Tips on protocol design for investigator-initiated studies to improve budgeting and billing 11. The role of the study calendar in clinical research billing 12. Improving communications during the research study 4

5 Overview 13. Pause for Questions 14. Introduction to the Coverage Analysis: Purposes 15. Review of forms needed 16. Development of a Coverage Analysis Step 1: Draft a grid Step 2: Review ICF Step 3: Review CTA/Budget Step 4: QCT Analysis Step 5: Which are routine costs? Step 6: How to document reasoning Step 7: Coding the CA 5

6 1. Regulatory risks of clinical research billing non-compliance 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 6

7 Risks Associated With Non-Compliance CRB risks can be grouped: 1. Billing for services that are already paid by the sponsor (double billing) 2. Billing for services promised free in the informed consent 3. Billing for services that are for research-purposes only 4. Billing for services that are part of a non-qualifying clinical trial 5. Billing Medicare Advantage Plan when claim should be directed to Medicare Administrative Contractor ( MAC ) 7

8 Challenges Cause of most research billing non-compliance: Breakdown in coordination Important information to coordinate What research studies are being conducted at the facility? Which patients are enrolled in a research study? Which services should be charged to payors and which charged to study account? Sponsor, grant, internal account Informed consent language Clinical trial agreement language Protocol Language 8

9 Coordination Who impacts research billing? Principal Investigator Clinical Research Coordinator vital communication coordinator IRB process Budget negotiators Clinical Trial Agreement negotiators Grant administration Information Technology Health Information Management Registration/Scheduling Medical center billing and coding Physician professional fee billing and coding Study fund managers Managed care contract negotiators.and others! 9

10 Current Research Regulatory Environment Cases of improper clinical trials billing Tenet Healthcare (Norris Cancer Ctr) Northwestern University Rush University Million Dollars Mayo Clinic Yale $0.0 $1.0 $2.0 $3.0 $4.0 $5.0 $6.0 $7.0 $

11 2. The importance of a Coverage Analysis (CA) for compliance 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 11

12 What is a Coverage Analysis? Systematic review of research related documents to determine the Medicare billing status of both the study itself and the items and services provided to the research subjects that are required by the study A tool to coordinate information for purposes of: Budgeting Billing Auditing 12

13 What a Coverage Analysis is not Guarantee of coverage in all cases Substitute for the pre-authorization process Based on individual investigators decisions or billing practices Substitute for the practice of medicine or physician judgment Treatment plan Black and white or perfect translation 13

14 Hypothetical CA: a way to coordinate information Physical Exam Code Infusion 1 Infusion 2 EKG RC RC RC Drug 123 J0123 SB SB Infusion RC RC Urinalysis NB NB Ultrasound ICF 2 weeks 12 weeks 24 weeks Comment RC RC RC RC Patient Diary N/A NB NB NB NB RC=Routine Care SB=Sponsor Billed ICF=Free in Informed Consent NB=Not billable to Medicare Aegis Aegis Compliance Compliance & Ethics & Ethics Center, Center, LLP LLP 14

15 3. An overview of Medicare rules for billing during clinical research studies 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 15

16 True or False? Medicare pays for standard of care during research studies. False: Medicare pays for routine costs during qualifying clinical trials 16

17 True or False? My friend in California says this service is covered when she provides it, so it s covered for us, too. Maybe: Medicare Administrative Contractors ( MACs ) can issue local coverage determinations ( LCDs ) that limit coverage in their area. If your friend has a different MAC, you may not be able to bill a service that she can. Possible for your friend to have a different MAC even if she works at a facility down the street from you 17

18 True or False? We have billed for this service hundreds of times and the claim is always paid by Medicare, so it must be covered. False: You cannot assume that just because Medicare has been paying for a service that it is a covered service 18

19 True or False? You are making clinical decisions when you decide something is not billable to Medicare. False. Decisions about whether a service is covered is not a clinical decision. It is a decision based on an analysis of the billing rules and coverage determinations made by CMS and Medical Directors at MACs. 19

20 Medicare s CRB Framework Medicare requires a five-part process for clinical research services coverage: 1. Does the study qualify for coverage? 2. What items and services are routine costs? 3. Do Medicare rules allow coverage of specific routine costs within a research study? 4. What is paid for by the sponsor? 5. What is promised free in the informed consent? 20

21 4. The basics of billing for research team members N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com

22 Billing Basics Before getting into the details of CRB, it is important to step back and understand: The billing system in the U.S. The structure of the Medicare Program Medicare is a driver of reimbursement across many payors, particularly for CRB Understanding some of the basics helps with budgeting, putting the CRB rules in context, and improves claims management 22

23 Structure of Medicare reimbursement for an outpatient service Service Technical component Professional component Medicare pays a technical component and professional component for all Part B services. Who receives which component depends upon the place of service.

24 Service provided in a physician office setting Service Technical component Professional component Medicare pays physician both components in one payment

25 Service provided in a hospital outpatient setting Service Technical component Professional component Medicare pays hospital Medicare pays physician

26 The Legal Structure of Medicare To understand Medicare research billing rules, it is important to step back and understand the legal structure of Medicare Statutory basis for Medicare coverage follows this principle: Medicare covers items and services that are reasonable and necessary to diagnose or treat illness or injury Known as the Reasonable & Necessary Rule 26

27 The Hierarchy of Medicare Rules The Statute National CMS National Coverage Determinations ( NCDs ) Manuals (e.g., Medicare Benefit Policy Manual, Medicare Claims Processing Manual) Local - MACs Local Coverage Determinations ( LCDs ) Medical Director articles Medical Director rulings Reasonable & Necessary Rule Document medical necessity when no coverage rule 27

28 Medicare Contractors Have Wide Discretion Example: CyberKnife No national uniform policy; regional decision Geography Has Role in Medicare Cancer Coverage, NYT December 16, 2008 [G]eography may play as big a role as medicine in determining which men diagnosed with prostate cancer are eligible for CyberKnife. As it turns out, Medicare pays for the treatments in 33 states but not in 17 others. Our guidance to them is that if there s no evidence it works, they shouldn t pay for it, said Dr. Steve Phurrough, Medicare s coverage director in Washington. The CyberKnife is a good example of a technology where you can review the evidence and come to different conclusions. 28

29 Implications of hospital vs. physician billing in CRB process The answer in the CA will be the same for hospital billing and physician billing but how the charges are presented on the claim forms will look very differently Hospital billing and physician billing should usually match during a research study with respect to when services are charged to the study account and when the item or service is billed normally Payment for hospital services versus physician services varies immensely Budgeting must take into account both the hospital charge and the physician charge (if the service is hospital-based) 29

30 5. How the budget structure influences what can be billed to insurance N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com

31 Medicare s CRB Framework Medicare requires a five-part process for clinical research services coverage: 1. Does the study qualify for coverage? 2. What items and services are routine costs? 3. Do Medicare rules allow coverage of specific routine costs within a research study? 4. What is paid for by the sponsor? 5. What is promised free in the informed consent? 31

32 First things first: What is a clinical trial agreement? A clinical trial agreement (CTA) sets out the obligations of parties involved in a research study The CTA sets out: what services are to be performed who does what who owns what how much money will be paid for which services extra regulatory obligations the parties will take on the rules of the road between the parties 32

33 Why is the CTA important for the research billing process? Whatever is paid for by the sponsor in the CTA cannot be billed to the subject or the subject s insurer If the CTA is not clear on what is being paid for by the sponsor, the document may be misinterpreted both by the sponsor and by regulators in the event of an audit The information in the CTA on what the sponsor is paying for must be communicated to the billing process Institutions may suffer unintended consequences based on what is written in the CTA 33

34 Non-industry contracts The concepts in this presentation apply equally to contracts for funding support with non-industry sponsors Most CRB compliance risks can occur without respect to whether the sponsor is industry, government, or a private foundation Negotiators of government contracts should coordinate with the individuals who negotiate the budget and be cognizant of their impact on the CRB process Offices within organizations that deal with government contracts should be brought into the CRB process training 34

35 What and where is the study budget? The study budget for industry-sponsored studies is typically an appendix or exhibit to the CTA and serves as the compensation detail The study budget and the main body of the contract are part of the same document they will be interpreted together 35

36 Operational issues that could impact the CRB process Many clinical trial agreements have been negotiated in parts One person negotiates the main body Another person negotiates the budget /compensation Protocol is incorporated but may not be reviewed carefully by either person, particularly if there is no formal MCA process in place Fundamental principle of Clinical Trial Agreements Singularity: A CTA is one contract with many parts Interpreted as a single legal document 36

37 Bringing a CRB perspective early to a CTA Best practice CRB processes analyze both the main body of the CTA and the study budget exhibit from a billing perspective Goal: Clarity in the final documents If sponsor is paying for all services, then the CTA and study budget should be clear and that should be reflected in a Medicare Coverage Analysis (MCA) or other communication tool to inform the CRB process If sponsor is only paying for some of the protocol services, then the study budget should be clear as to which services are being paid for so there is no confusion in developing the MCA Ambiguities in the CTA and study budget will usually be interpreted by insurers to their benefit (i.e., no billing) 37

38 Main body of the CTA: Case studies of language Examples of clauses (risky language): Payment for Study services are set out in Exhibit B. Such compensation constitutes payment for all of the Institution s costs for conducting Study services. Sponsor agrees to pay Institution in accordance with Exhibit B. Institution agrees not to bill any third-party payer for services required by the Study. Exhibit A sets out the payment schedule to Institution for Study services. Unscheduled imaging services shall be invoiced to sponsor at $350 per service. 38

39 Main body of the CTA: Case studies of language Examples of clauses (neutral language): During the term of the Study, Sponsor agrees to provide financial support for the Study in accordance with the budget set out in Exhibit A. Payment to Institution for items provided and services performed by Institution during the Study are set out in Exhibit A. Negotiations will not always be able to produce completely neutral language in the main body of the CTA; if the main body contains discussion of specifics of the financials, then be precise and ensure that the main body of the CTA and the study budget language do not contradict each other 39

40 Structure of Financial Provisions: Compensation Exhibit/ Study Budget There is no standard approach to the Compensation Exhibit each sponsor tends to have its own format Some structures utilized: Payments for research service at milestones Note: Is research service defined? Be clear which services are considered research services Spreadsheet with payments based on schedule of events Note: Best practice 40

41 Structure of Financial Provisions: Compensation Exhibit/ Study Budget Consider adopting a consistent approach for the compensation exhibits: the more detail on which services are being paid for, the better The MCA can serve as a tool for budgeting and lends itself to be used as the compensation exhibit Negotiating Suggestion: Watch out for footnotes! Avoid footnotes in the study budget, if possible 41

42 Operational issues that could impact the CRB process Many clinical trial agreements have been negotiated in parts One person negotiates the main body Another person negotiates the budget /compensation Protocol is incorporated but may not be reviewed carefully by either person, particularly if there is no formal MCA process in place Fundamental principle of Clinical Trial Agreements Singularity: A CTA is one contract with many parts Interpreted as a single legal document 4 2

43 Tips on protocol design for investigator-initiated studies to improve budgeting and billing 43

44 The design of the study impacts billing 3 Items to think about in protocols: 1. Loose use of the term research If the service is being used for research purposed and clinical care, then discuss the clinical care When a protocol only talks about the research aspects of a service, an auditor could ignore the clinical usefulness of the services 4 4

45 The design of the study impacts billing 3 Items to think about in protocols: 2. Stating a potential benefit If protocol or informed consent form states that the subject will receive no benefit from the study, then no services will be billable Describe in the protocol and the informed consent any potential benefit (though do not guarantee benefit) 4 5

46 The design of the study impacts billing 3 Items to think about in protocols: 3. What are the objectives in a Phase 1 study? Is it necessary in the study to state principal and secondary objectives of the study? Or can all objectives be stated without rank? Some Medicare Contractors and auditors have denied coverage to Phase 1 studies when measurement of therapeutic outcome is not a primary objective or a clearly articulated objective 4 6

47 6. How the language of the Informed Consent Form influences what can be billed to insurance N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com

48 Medicare s CRB Framework Medicare requires a five-part process for clinical research services coverage: 1. Does the study qualify for coverage? 2. What items and services are routine costs? 3. Do Medicare rules allow coverage of specific routine costs within a research study? 4. What is paid for by the sponsor? 5. What is promised free in the informed consent? 48

49 Role of the Informed Consent Form Interpreting the ICF ICF interpreted for MCA from the perspective of the subject Plain meaning of the words used in the informed consent Promises made to subject regarding what is free must be kept If two sentences in Costs section could reasonably be interpreted in a way that they contradict each other, then reword 49

50 Research Informed Consent: Context OHRP & FDA Rules: 45 CFR & 21 CFR 50.20: The information that is given to the subject or the representative shall be in language understandable to the subject or the representative. Goal: Language in 6 th to 8 th grade reading level Government reviews and audits of ICF: Interpreted from the perspective of the subject The ICF means what it says: assumes plain meaning of the terms 44

51 ICF & Added Costs Section Regulation: 45 CFR (b)(3) & 21 CFR 50.25(b)(3) require the ICF include, when appropriate, any additional costs to the subject that may result from participation in the research If the added costs section of the informed consent form states that an item or service will not be charged to the patient, then the provider cannot bill for that service Note: The regulation does not require that the ICF list the services that are or are not charged, rather it requires the ICF to list the additional costs the patient will incur as a result of participating in the study (many routine costs are not costs resulting from participation) 51

52 Problematic Added Costs Language You or your insurer will have no costs for participating in this research study. (Subject/insurer may not be billed for any protocol-required items or services, nor for complications/injuries or other costs associated with participation) Your routine medical care will be billed in the usual way. However, you will not be charged for any study visits or services. (Inconsistent terms within the same document) You will be responsible for the costs of any services you would have received if you did not enroll in this research study. However, you will not be billed for any lab services or imaging services. (Inconsistent terms within the same document) 52

53 Added Costs Section Contemplating the CRB Process Language which keeps the ICF neutral : You will be responsible for the costs of services required by the research study that are routine to treat your condition. You will not be responsible for the costs of services that are required only because you are enrolled in the research study. Language which specifically identifies services that will not be billed (if IRB desires specifics) You will be responsible for costs for care you would have received if you were not enrolled in this research. However, you will not be responsible for the costs of the CT scan conducted at the start of each drug cycle. 53

54 Medicare CRB Rules: The Regulatory Specifics 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 54

55 In a Nutshell Medicare covers routine costs in a qualifying clinical trial but note that all other Medicare rules still apply. 55

56 7. What does Medicare mean by a qualifying clinical trial? 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 56

57 Qualifying Status Research study must meet CMS qualifying clinical trial criteria for any items and services in the study to be confidently covered. Government and Drug Trials: CMS Clinical Trial Policy (NCD 310.1) Device Studies: Device study coverage rules from regulations and Medicare Benefit Policy Manual 42 CFR Part 405, Subpart B (42 CFR et seq.) Ch. 14 of the Medicare Benefit Policy Manual 51

58 Qualifying Clinical Trials ("QCTs") Part 1 Deemed Studies These studies are deemed to have 7 characteristics CMS wants to see in a study it will cover 1. Studies funded by NIH, CDC, AHRQ, CMS, DOD, and VA 2. Studies supported by centers or cooperative groups funded by NIH, CDC, AHRQ, CMS, DOD, and VA; 3. Studies being conducted under an IND application; or 4. IND exempt studies under 21 CFR 312.2(b)(1) 58

59 Qualifying Clinical Trials ( QCTs ) Part 2 Necessary Requirements 1. The study must investigate an item or service that Medicare pays for (falls in a benefit category) 2. The study must enroll patients with diagnosed disease 3. The study must have therapeutic intent 59

60 Benefit Category Test NCD lists 72 benefit categories Drug studies: Drugs and biologicals 60

61 Diseased Subjects Test Medicare only covers items and services that are reasonable and necessary to diagnose or treat illness or injury (with limited exceptions) Requirement comes from Medicare statutory principles CA documents the subjects diagnosis CTP: Trials of diagnostic interventions may enroll healthy patients in order to have a proper control group. 61

62 Therapeutic Intent Test For the time being, application of therapeutic intent criterion is deferred to local Medicare Contractors Principally an issue for Phase I drug studies Can be vast differences from one Medicare contractor to another 62

63 Therapeutic Intent There are two discussions of therapeutic intent in the CTP: The trial must not be designed exclusively to test toxicity or disease pathophysiology. It must have therapeutic intent. The principal purpose of the trial is to test whether the intervention potentially improves the participants' health outcomes. 63

64 Qualifying Clinical Trial Test - Recap It is really a four part test: Is the trial one of the deemed studies? Does the trial assess something in a Medicare Benefit Category? Does the trial enroll people with diagnosed disease? Does the trial have therapeutic intent? If no to any one of these, it is not a QCT 64

65 Qualifying /Approved Device Trials 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 65

66 Device Trials Always check with your Medicare Administrative Contractor is Palmetto for the Richmond Virginia area for their specific requirements 66

67 Category A Experimental Devices Generally not covered However, Medicare may cover routine costs, if the device is used for a life-threatening condition. Medicare contractor decides Device itself must be provided free 67

68 Category B Non-Experimental Devices These devices can be covered under Medicare. FDA approved IDE study protocols restrict investigational devices shipment to a limited number of clinical sites for testing on a specific number of patients. Medicare coverage is based on the device continuing to meet criteria that led to the FDA category designation 68

69 Clinical Trials Billing Medicare may cover procedures using devices with an IDE that have been categorized as non-experimental /investigational (Category B) Medicare only covers those procedures if: They involve a device the FDA has determined is nonexperimental/investigational (Category B), and The device is furnished in accordance with FDAapproved protocols governing clinical trials 69

70 8. What does Medicare mean by routine costs? 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 2013 Aegis Aegis Compliance & & Ethics Center, LLP LLP 70

71 Routine Costs from the Medicare CTP Items or services that are typically provided absent a clinical trial (e.g., conventional care); [Note: Not the same as standard of care ] Items or services required solely for the provision of the investigational item or service (e.g., administration of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications; and Items or services needed for reasonable and necessary care arising from the provision of an investigational item or service--in particular, for the diagnosis or treatment of complications. 71

72 Routine Costs Short Version 1. Detection, prevention, or monitoring of complications; 2. Administration of investigational item; or 3. Conventional care 72

73 Detecting, preventing, or monitoring complications Identify nexus between the item or service and a known potential side effect of the item or service What are the potential side effects of the drug? What are the potential complications of use of the device? 73

74 Detecting, preventing, or monitoring complications Places in which CAs identify potential side effects Protocol Informed Consent Product Label Drug compendium discussion AHFS-DI American Hospital Formulary Service Drug Information NCCN National Comprehensive Cancer Network Drugs & Biologics Compendium Thompson Micromedex DrugDex Clinical Pharmacology 74

75 Administration of Investigational Item What is required to administer the investigational item? Surgery? Infusion? Note: must be something that would be covered outside of study if similar therapy or procedure occurs. 75

76 Conventional Care CAs should identify objective practice guidelines 1. Professional association guidelines (e.g., National Comprehensive Cancer Network/NCCN) 2. Peer-reviewed literature 3. Significant textbooks 4. Disease-based associations 5. NIH recommendations 6. Guidelines.gov 76

77 Conventional Care: Example NCCN Practice Guidelines for Cancer of the Oropharynx: follow-up Physical exam Year 1: every 1-3 months Year 2: every 2-4 months Years 3-5: every 4-6 months > 5 Years: every 6-12 months 77

78 Additional Note: All Other Medicare Rules Apply Coverage is available if Medicare covers the routine cost outside of clinical trial MCA applies normal Medicare rules on top of any item or service identified as a routine cost 78

79 Other Medicare Rules Example: Rule against coverage of selfadministered drugs (Medicare Benefits Policy Manual, Ch. 15, Sec. 50.5) Exception examples: anti-emetics; oral anti-cancer drugs 79

80 Routine Costs vs. Standard of Care Just because the physician normally performs a service at a given frequency for similar patients not on trial does not mean the service qualifies as a routine cost E.g., PSA exams for prostate cancer patients Study calls for monthly PSA Physician typically does monthly PSA and argues they are therefore conventional care and consequently routine costs NCCN guidelines call for every 3 months No other objective evidence produced by physician to support medical necessity of monthly PSAs 80

81 Routine Costs vs. Standard of Care EKG performed 3 days after each infusion of cardio-toxic drug during trial Routine cost: detecting and monitoring known side effects Also performed at annual follow-up visits for life Is EKG at follow-up a routine cost? 81

82 9. The importance of the research coordinator in ensuring clinical research billing is compliant 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 82

83 83

84 10. Tips on protocol design for investigatorinitiated studies to improve budgeting and billing 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 84

85 The design of the study impacts billing 3 Items to think about in protocols: 1. Loose use of the term research If the service is being used for research purposed and clinical care, then discuss the clinical care When a protocol only talks about the research aspects of a service, an auditor could ignore the clinical usefulness of the services 85

86 The design of the study impacts billing 3 Items to think about in protocols: 2. Stating a potential benefit If protocol or informed consent form states that the subject will receive no benefit from the study, then no services will be billable Describe in the protocol and the informed consent any potential benefit (though do not guarantee benefit) 86

87 The design of the study impacts billing 3 Items to think about in protocols: 3. What are the objectives in a Phase 1 study? Is it necessary in the study to state principal and secondary objectives of the study? Or can all objectives be stated without rank? Some Medicare Contractors and auditors have denied coverage to Phase 1 studies when measurement of therapeutic outcome is not a primary objective or a clearly articulated objective 87

88 11. The role of the study calendar in clinical research billing 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 88

89 Study Calendars Study calendars help orient reviewers to where the subject is in the study The study calendar helps to sync the schedule of events with the CA Example: A charge for a CBC on 9/16/12 which CBC is it? 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 89

90 Hypothetical CA Code Baseline C1 W1 C1W2 C1W3 C1W4 C2W1 C2W2 Physical Exam S P P S P P CMP S P P S P P CBC S P P S P P Blood Draw S P P S P P DEXA scan Study Drug Admini stration S S S S S P P P P P

91 Collecting Protocol Event Dates John Smith ICF: 8/14/12 Physical Exam Code Baseline C1 W1 C1W2 C1W3 C1W4 C2W1 C2W2 8/16/12 9/2/12 9/9/12 9/16/12 10/6/12 10/13/12 CMP 8/16/12 9/1/12 9/9/12 9/16/12 10/6/12 10/13/12 CBC 8/16/12 9/1/12 9/9/12 9/16/12 10/6/12 10/13/12 Blood Draw DEXA scan Study Drug Admini stration 8/16/12 9/1/12 9/9/12 9/16/12 10/6/12 10/13/12 8/18/12 9/21/12 9/2/12 9/9/12 10/6/12 10/13/12 9/2/12 9/9/12 10/6/12 10/13/12

92 12. Improving communications during the research study 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 92

93 Reality This isn t going to happen overnight Try piloting ideas for CRB claims management Do not be afraid to re-think plan after results of piloting Personal Observation: We have yet to see a CRB process which after 1 year looks the same as its roll-out 93

94 The importance of databases Sharing information and communication is a critical feature of managing clinical research billing Databases and an information platform are the most common solutions 94

95 The importance of databases What information to collect? Study identification IRB status Subject enrollment Study calendars Coverage Analyses Study document housing 95

96 13. Pause for Questions 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 96

97 Workshop Discussion 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 97

98 14. Introduction to the Coverage Analysis: Purposes 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 98

99 Screening C1W1 C1W2 C1W3 C1W4 C2 W1 C2 W2 C2 W3 C2 W4 After Discontinuation Phys Exam X X X X X X X X X X ECG X X Echo cardiogram Chest CT or MRI , X X X X X X Abdominal CT or MRI , X X Pelvis CT or MRI , X X Bone Scan X X CBC w/diff X X X X X X X X X X Comprehensive Metabolic Panel X X X X X X X X X X Study Drug J9999 X X X X

100 Screening C1W1 C1W2 C1W3 C1W4 C2 W1 C2 W2 C2 W3 C2 W4 After Discontinuation Phys Exam P P P P P P P P P NB ECG P NB Echo cardiogram Chest CT or MRI , P S NB P P NB Abdominal CT or MRI , P NB Pelvis CT or MRI , P NB Bone Scan P NB CBC w/diff P P S S S P S S S NB Comprehensive Metabolic Panel P P S S S P S S S NB Study Drug J9999 S S P S

101 15. Review of forms needed 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 101

102 First Question Is the study a new study or a active study? 102

103 Basic Documents Needed Protocol CTA/Budget Funding Document Informed Consent Form IND Status drug study FDA IDE Letter device study 103

104 General Order of Steps for Developing an CA: Proposed Study : 1. Develop grid 2. Perform QCT analysis 3. Identify items and services hard-wired free into protocol 4. Determine items and services that are routine costs 5. Determine if routine costs are covered by Medicare 6. Check proposed contract to determine if offered budget covers items and services that are not billable 7. Negotiate contract/budget 8. Finalize added costs section of informed consent 9. Finalize grid once study approved 104

105 Sections 16 Development of a Coverage Analysis Step 1: Draft a grid Step 2: Review ICF Step 3: Review CTA/Budget Step 4: QCT Analysis Step 5: Which are routine costs? Step 6: Document reasoning Step 7: Coding the CA 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 105

106 General Order of Steps for Developing an CA: Active Study 1. Develop grid 2. What items and services are promised free in the informed consent? 3. What items and services are paid for by the sponsor? 4. Qualifying clinical trial (QCT) analysis 5. Determine items and services that are routine costs 6. Determine if routine costs are covered by Medicare 7. Apply Medicare rules to the routine costs 8. Finalize grid 106

107 Recall: Qualifying Clinical Trial Status

108 Document the QCT Analysis Process Question Yes No Comment Deemed study? Item or service falls within a benefit category? Enrolls subject with diagnosed disease? Study designed with therapeutic intent? Qualifying Clinical Trial? 108

109 Document the QCT Analysis Process Question Yes No Comment Deemed study? X IND # 55,512 Item or service falls within a benefit category? Enrolls subject with diagnosed disease? Study designed with therapeutic intent? Qualifying Clinical Trial? X X X X Drugs & Biologicals Crohn s Disease Include direct quote from protocol and reference page number To determine the efficacy of [study drug] in minimizing occurrences of abdominal pain over 24 week period. 109

110 Recall: Device Trial Qualifying Status Device Trial Coverage: Coverage deferred to Medicare Contractor approval or local rules Category A IDE: covered when studying a life-threatening condition Category B IDE: generally covered PMA: generally covered with approval and may not always need approval Note: Carotid Artery Stent PMAs must be approved by the Medicare Contractor Misc Situations: Labeled Use: generally covered because the study is likely not investigating the device, but collecting outcomes data HUD: requires approval by Medicare Contractor (not necessarily a trial) 110

111 Document Device Trial Qualifying Question Does the device have an IDE? Question Is the device approved by the FDA? Yes No Yes No Coverage Eligibility Summary If the device has an IDE what category is it? Category A Category B If the device is FDA approved is it being studies on-label or offlabel? On-Label Off-Label Comments Comments Question Yes No Supporting Explanation Is the study eligible for coverage? 111

112 Routine Cost Short version approach to routine costs used in MCAs: 1. Detection or prevention of complications 2. Conventional care 3. Administration of investigational item If study documents are not clear: will each subject enrolled in the study need the item or service for the patient s clinical management? 112

113 Which of the events are justified for billing under the coverage rules as routine costs? Physical Exam Code Infusion 1 Infusion 2 2 weeks 12 weeks 24 weeks EKG RC RC RC Drug 123 J9999 SB SB Infusion RC RC Urinalysis NB NB Ultrasound ICF RC RC RC RC Patient Diary N/A NB NB NB NB RC=Routine Care SB=Sponsor Billed ICF=Free in Informed Consent NB=Not billable to Medicare

114 Document Reasoning EKG: The EKG in this study is conventional care. Practice Guidelines for treatment of XYZ Condition recommend EKG at this frequency. [Cite Guidelines]. 114

115 Document Reasoning EKG: The EKG in this study is to detect complications. The study drug has known cardiotoxic effects. Protocol, p

116 Research Codes 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 116

117 Research Coding Principal matters: V70.7 diagnosis code Q0/Q1 modifiers Condition Code 30 (research setting) ClinicalTrials.gov number 117

118 Where to find the rules Medicare Claims Processing Manual Chapter 32, Section 69.6 Requirements for Billing Routine Costs in Clinical Trials Note: references to these research coding rules are scattered throughout Medicare rules and commentary, but the Claims Processing Manual provides the most concise resource and reference. 118

119 ClinicalTrials.gov number When a study is registered with clinicaltrials.gov (a website managed by the NIH), it is assigned an 8 digit number Providers may report the clinicaltrials.gov number on the claim form, but this is strictly voluntary today. New guidelines go into effect January 1, 2014 CMS conducts monthly aggregations of claims using the clinicaltrials.gov code 119

120 V70.7 Examination of participant in clinical trial. Used as the secondary diagnosis for all claims with research-related items and services. Note: If used as the primary diagnosis, then the claim will be rejected. Used for inpatient and hospital outpatient claims and physician billing. 120

121 Q0/Q1 Modifiers placed after CPT code on: Hospital outpatient claims Physician billing claims Not used in inpatient hospital claims Not used for services on claims which are not related to the research study Line item by line item use 121

122 Q0/Q1 Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study. Q1 - Routine clinical service provided in a clinical research study that is in an approved clinical research study. 122

123 Q0 Investigational clinical services are defined as those items and services that are being investigated as an objective within the study. Investigational clinical services may include items or services that are approved, unapproved, or otherwise covered (or not covered) under Medicare. Examples: Study drugs that are billable Category B devices Investigational devices with Medicare approval Laboratory tests which are identified in the objectives as instrumental to the hypothesis 123

124 Q1 Routine clinical services are defined as those items and services that are covered for Medicare beneficiaries outside of the clinical research study; are used for the direct patient management within the study; and, do not meet the definition of investigational clinical services. Routine clinical services may include items or services required solely for the provision of the investigational clinical services (e.g., administration of a chemotherapeutic agent); clinically appropriate monitoring, whether or not required by the investigational clinical service (e.g., blood tests to measure tumor markers); and items or services required for the prevention, diagnosis, or treatment of research related adverse events (e.g., blood levels of various parameters to measure kidney function). (emphasis added) 124

125 Condition Code 30 Used on the claim form whenever a V70.7 is used One-for-one use 125

126 A note on the medical record Section 69.3 of Ch. 32 also contains the following: The billing provider must include in the beneficiary's medical record the following information: trial name, sponsor, and sponsor-assigned protocol number. This information does not need to be submitted with the claim but must be provided if requested for medical review. (emphasis added) 126

127 Add-on that applies to all: Identifying treatment of complications Note that in some studies, the sponsor will pay for unscheduled events and treatment of complications. A system needs to be devised to identify these Suggestion: Flag studies in database which pay for treatment of complications or unscheduled events Batch ED census and bump against subject database for the flagged studies Hold charges for any matched Obtain information from PI/study coordinator 127

128 Useful for Effective CRB Claims Management Database of research studies Database of research subjects CAs/tool

129 Questions? 4147 N Ravenswood Ave Ste. 200 Chicago, IL www. aegis- compliance. com 129