Dr. Kamil--I represent the California Urologic Association. We have had
quite a number of calls from California members in the past few months asking for
assistance with Wellpoint regarding what they consider to be extremely low
reimbursement rates for microwave therapy for BPH performed in the office. I
know you have had discussions about this topic with several others since we have
all been in communication but I wanted to try and clear the air and if
agreeable with you, send out an article to notify the state's urologists about what
they can expect from Wellpoint in this regard. As you know, the reimbursement
for CPT code 53860 (microwave thermotherapy) has been paid without regard to
site of service. While the payment for this code might be acceptable when made
for the professional fee only when performed by a surgeon in the hospital, it
fails to take into account the overhead associated with the procedure when it
is provided in an office setting which is where microwave thermotherapy for
BPH is most often done. The cost of the disposable items used in this treatment
alone exceed the payment made by Blue Cross therefore the doctor would lose
significant amounts of money with each patient treated. In the past, I
understand physicians were told that the Blue Cross computers were not able to
discern site of service and make appropriate adjustments in reimbursement. However,
even when doctors offered to submit paper claims that could be processed
individually, they were told this was not acceptable to Blue Cross.

Most recently, I understand you resolved this issue with urologists in
Northern California promising to adjust their claims and make payment at the
appropriate level. While we do not adhere to the Medicare published rates as a
necessary standard, they do provide appropriate comparisons. In this case, their
allowed reimbursement for this procedure when performed in a doctor's office is
dramatically higher than that which has been paid by Blue Cross since they
recognize the overhead costs involved in providing the service. This is all
that we ask: that Blue Cross acknowledge the attendant costs involved with in
office treatment of BPH and make payment appropriate to the site of service.
This would be appropriate for all the treatments currently considered in the
category of MIST (minimally invasive surgical therapy) which include microwave,
TUNA (transurethral needle ablation), WIT (water induced thermotherapy) and
interstitial laser therapy (most often done with the Indigo laser). The American
Urologic Association recognizes each of these as standard choices for
treatment of benign prostatic hypertrophy. High intensity focused ultrasound and
ethanol injection are considered investigational at the present and balloon
dilation is not considered a standard treatment option. For any questions in this
regard, please review the published current guidelines (The American Journal of
Urology Review, April 2004, Vol. 2, No. 4, Supplement 3, pages 2-18). The
California Urologic Association agrees with and supports these guidelines as
evidence based, scientifically supported conclusions based on an exhaustive review
of the literature with input from a wide range of experts.

My only concern is a statement apparently made to one of the urologists you
spoke with that suggested that the decision to adjust his claim was unique to
his situation only and that each urologist might have to negotiate his or her
own new understanding with Blue Cross about reimbursement based on site of
service. I would hope that this was his misunderstanding and that as the Blue
Cross computers are updated to consider location when deciding payment that they
make that determination across the board for all submitting specialists. If
this were done, it would be a happy day for our members and their patients.
Moreover, it would serve Blue Cross' best interests as well since it has been
very clearly demonstrated that thermotherapy for BPH provided in an office
setting is much more cost effective for the provider than that performed in either
an ambulatory surgical center or a hospital. In other words, the patient, the
physician and Blue Cross all benefit from advanced technology designed to treat
a common medical condition with improved outcomes, decreased morbidity and
substantial cost savings. We always take delight in these win-win situations.

I look forward to your reply confirming that Blue Cross will now take the
site of service into account when determining payment for thermotherapy for
obstructive, symptomatic BPH performed in an office setting for all providers
contracted with you. Our goal is nothing more than seeking fair levels of
reimbursement allowing us to continue to provide high quality medical care to all of
our patients. Thank you so much for attending to this concern. I eagerly look
forward to hearing from you.

Yours,

Jeffrey Kaufman M.D., F.A.C.S.
Diplomate, American Board of Urology
California Urologic Association
720 North Tustin Ave., Suite 101
Santa Ana, CA 92705
714-973-4600
fax 714-547-1259