Access to Gallium-68 scan could change
There is an issue now before the U.S. Congress that could affect the NET community. Medicare reimbursement of the Gallium-68 (Ga-68) PET/CT will be changing next year and there is a concern that this change could reduce access to this effective NET diagnostic procedure.
What’s going on
In 2008, Medicare (Centers for Medicare & Medicaid Services) simplified how Medicare paid for PET imaging. The simplification reduced an infinite combination of supplies and tracers to a few PET bundles based on the cost of the radiopharmaceutical. These bundles allowed a provider to bill for all PET imaging in a simplified manner.
To accommodate new imaging agents, Medicare allowed a provider to bill new agents outside the bundle and be paid for separately as a drug for a period of three years.
On Jan 1, 2020, Ga-68 PET/CT scans will no longer be paid for separately and while Medicare will still cover the scan (as appropriate) at the highest bundle level, this reimbursement will be less than the cost of the Ga-68.
On October 18, 2019, an opinion piece from NETRF Board member and NorCal CarciNET Community President Josh Mailman (“CMS policy shouldn’t penalize those with rare disease”) was published by The Hill. The opinion piece highlights the challenges with the current method that Medicare/CMS uses to pay for radiopharmaceuticals.
The Medicare Diagnostic Radiopharmaceutical Payment Equity Act of 2019 (H.R. 3772), which many in the nuclear medicine community support, will impact Medicare payments for imaging only. This bill would direct Medicare to pay separately for those diagnostic radiopharmaceuticals with a per-day cost that exceeds $500. It is not looking at broader medical payment, billing, or cost issues.