David Matyas and Jason Caron, attorneys in the Health Care and Life Sciences practice in the Washington, DC, office, coauthored an article titled “Catching Up to Technology: Proton Beam Therapy Coverage and Reimbursement Principles Continue to Evolve.”
Following is an excerpt:
Proton beam radiation therapy has significantly developed over the last few years with treatment centers coming online in Illinois, Virginia, Oklahoma, and Pennsylvania. In addition, intentions to build new centers have been announced in locations throughout the country, including Arizona, California, Maryland, Minnesota, New York, Ohio, and Tennessee. This article is a summary of recent developments in the Medicare payment and coverage for proton beam radiation therapy (Proton Therapy).
Proton Therapy centers generally are enrolled in Medicare as either (1) hospital provider-based centers or (2) freestanding centers. With respect to hospital provider-based centers, the payment rates are set nationally through the Medicare Hospital Outpatient Prospective Payment System (HOPPS) based on cost data reported by hospitals.
With respect to Proton Therapy provided in freestanding centers, the various Medicare Administrative Contractors (MACs) establish the payment rates. Given the relatively small number of freestanding centers currently operating in the United States, only a small number of MACs have set payment rates for Proton Therapy (First Coast Options Services (First Coast), National Government Services (NGS), and Trailblazer Health Enterprises (Trailblazer).