Process of New Technology Coverage and Current Medical Physics

The process of covering new technologies in medicine is complicated, both from the viewpoint of government agency reimbursement through the Centers for Medicare and Medicaid Services (CMS) and through the private sector carrier reimbursement entities such as Aetna, Blue Cross/Blue Shield and the like. The process is further complicated by coverage differences in the Hospital environment versus coverage in clinics and “stand-alone ” treatment centers. Coverage decisions generally begin with CMS assignment of temporary coverage codes in the Hospital environment for new procedures and technologies. These take the form of the so-called “G ” codes and are put forward for coverage by medical specialty societies when these professional organizations have agreed that the procedure or technology is “ready for prime time. ” Coverage decisions include actual dollar amounts for performing the procedure under current CMS rules. The medical specialty society then must submit the procedure to rigorous review for eventual coverage in the clinic or stand-alone cente