How can I find how much Medicare will reimburse my facility for Rubidium?
Medicare packages diagnostic radiopharmaceuticals under the outpatient prospective payment system (OPPS), so hospitals will not receive any separate payment for Rubidium.
For non-hospital imaging centers and offices, Medicare does not set a national fee for radiopharmaceutical reimbursement, but allows each contractor to determine the payment amount. Medicare administrative contractors (MACs) use a variety of methods to determine the reimbursement for radiopharmaceuticals.
Some Medicare contractors, such as Noridian, have received enough claims that they have been able to determine an average price. These fees are listed on the contractor’s website under contractor-priced fee schedules. Palmetto GBA and other contractors will pay based on 95 percent of the average wholesale price (AWP), while others, such as Novitas, will pay 100 percent of the acquisition cost as reported on the claim.
Check your MAC’s website for the method used in your state. If you are not sure who your MAC is, use Medicare’s interactive map, which can be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.