I am an anesthesiologist. The leadership of my small group of 15 physicians has been negotiating a merger with the large group in a nearby city. They have made some compelling arguments for the strategic advantages of an affiliation with a larger entity. But as logical as the rationale for merging is, so are the concerns and the questions raised by detractors. It is just not clear that all the disruption of closing out our current entity and transitioning to employment status with the big group will result in a more favorable situation for us as individuals or even as a division of the new entity. I personally worry about losing control of my practice and the clinical autonomy that attracted me to this practice in the first place. The fact is that I am still unsure how I will vote when we all get together to make a final...

Many “Covered Entities” within the meaning of the privacy and security provisions of the Health Insurance and Portability Act of 1996 (HIPAA) are managing more and more of their patient information electronically.  Indeed, not moving to electronic health records (EHRs) may cost physicians a percentage of their Medicare remittances—or at least the loss of a potential bonus of up to $44,000—under the EHR Incentive Program, as discussed in our last several Alerts.Collecting, analyzing, reporting and storing electronic patient information present perhaps even greater HIPAA challenges than does the use of paper records, however.  Data entered on a computer can be copied more easily, more cheaply, more prolifically and even passively.  Once unsecured data are moved from the computer on which they are created to other media, manually or wirelessly, controlling the information becomes nearly impossible.  The key word in the preceding sentence is “unsecured.”  The recently finalized HIPAA regulations on Breach Notification impose...

Anesthesiologists and pain physicians who have been receiving bonuses for participating in Medicare’s Physician Quality Reporting System (PQRS) should continue to do what they have been doing.  The proposed Fee Schedule rule (NPRM) for 2013 does not contain any new requirements affecting those who are already successfully participating, as we noted summarily in last week’s Alert.For physicians who have yet to earn a PQRS incentive payment, the NPRM would make reporting easier in future years.  This is important, because failure to report PQRS measures will result in financial penalties beginning in 2015—based on reporting in 2013.  The amount of the payment adjustment, positive or negative, will be as follows: 2013+0.5% 2014+0.5% 2015-1.5% 2016 on-2.0% CMS has stated that one of its major goals in developing its proposed changes was to increase participation to 50% of eligible providers in 2015.  In 2010, the overall level of participation was only 24 percent.  (“2010 Reporting Experience, Including Trends (2007-2011): Physician...

Another Medicare compliance deadline approaches, and it has attracted a fair amount of attention.  The good news is that it will apply to few pain physicians and even fewer anesthesiologists.  Sometimes it is necessary to explain a new rule or requirement just so that our readers know not to worry.  This is one of those times.By July 1, 2012, those physicians and facilities that are affected are expected to be in compliance with the “3-day payment policy.” The 3-day payment window applies to certain outpatient services provided by hospitals and hospitals’ wholly owned or wholly operated entities, including physician practices.The policy has applied to diagnostic services and related non-diagnostic services since 1998.  The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 broadened the definition of related non-diagnostic services that are subject to the payment window to include any non-diagnostic service that is clinically related to...

  A moderated discussion of compensation strategies at last week’s MGMA-ACMPE AAA meeting showed a good deal of flexibility in allowing anesthesiologists to job-share or otherwise to reduce their hours. The groups represented at the discussion were also creative in compensating members for business development and administrative activities. If case loads decline substantially, layoffs may occur, although they are the least favorite option.Along with more than 300 other MGMA-ACMPE Anesthesia Administration Assembly (AAA) members and exhibitors, we participated in the annual AAA meeting in Scottsdale last week.  One breakout session discussion group in particular was so informative that we obtained permission to bring a summary to our readers.About 60 individuals attended the discussion of compensation strategies moderated by Stephen E. Comess, Executive Director, United Anesthesia Services, P.C.  Mr. Comess got the ball rolling on responses to twelve prepared compensation management scenario questions by giving each member of the audience a playing...

Anesthesia Business Consultants (ABC) keeps a keen eye on the continued proliferation of electronic medical record (EMR) technology.  It is not enough to adopt the latest technology, ABC investigates the latest technological advancements in EMR, carefully testing new systems to ensure their compatibility with our renowned OneSourceAnesthesia platform, and working with leading-edge software providers.  Our goal:  to facilitate a smooth transition from paper to electronic billing of anesthesia services.  ABC strategically considers each upgrade from both a technological and functional update—in an effort to provide clients an unparalleled level of service. OneSourceAnesthesia Successfully Integrates EMR with Epic Anesthesia ABC is pleased to announce that we have successfully interfaced with Epic Anesthesia.  ABC worked with Orange Regional Medical Center and its Epic project team on a repeatable approach for electronic professional billing at Orange Regional Medical Center, located in Orange, New York.  The records and billing information, when combined with the automated...

Virtually all large anesthesiology practices have a corporate website. Some are quite detailed and complex. Fewer medium and small practices maintain a web presence. Should every practice consider creating a practice website or upgrading its current site?After examining a number of anesthesia practice websites, one can see that most have common elements and purposes. Before considering website design, the practice should seriously consider the purpose of the website and its intended effects.The reasons given by anesthesia practices for expending the time and money needed to produce an effective website are to implement one or more of the following:Establish a “web presence”Recruit anesthesia personnel via the websiteProvide patient informationAssist in the patient billing processSchedule anesthesiologists via surgeon preferenceInternal uses such as maintaining call schedules, document retrieval and communications.Marketing to patients, surgeons and facilities seeking anesthesia coverage.WEB PRESENCECurrently, almost every business has a website, so anesthesiology practices may believe that they too should...

Consolidation in the hospital sector has proceeded at a rapid pace in the last few years.  Hospitals, like anesthesiologists and other health care professionals and organizations, are seeking the advantages of combined size to secure their future in a marketplace undergoing a revolution with an unknown outcome.  Oral argument before the Supreme Court on the constitutionality of the Affordable Care Act, discussed in our Alert of April 2nd, did nothing to mitigate the uncertainty. The Federal Trade Commission (FTC) scored a significant victory last week when a federal District Court judge in Rockford, Illinois halted the acquisition of Rockford Health System by a competitor, OSF Healthcare System, until the FTC can conclude an administrative review of the deal (including all appeals, which means a delay of at least a year even if the hospitals ultimately prevail). According to the FTC, the acquisition would violate antitrust law by reducing competition in...

The variety of commonly used modalities for the management of post-operative surgical pain makes it imperative that practitioners understand the specific documentation and billing requirements of each option. Listed below are the five most common approaches and their corresponding claims submission guidelines. As is always the case, reimbursement will vary by payer.Intravenous Patient-Controlled Analgesia Management (IV PCA) – Surgeons are reimbursed for routine post-operative pain management as part of their global fee. Due to this fact, Medicare does not allow anesthesiologists to bill for this service. However, many non-Medicare payers do. The physician must see the patient on a post-operative day and document a progress note to include a problem focused history and exam with straightforward medical decision making. The typical code billed for this service is “subsequent inpatient visit” code 99231 (2 units).Patient-Controlled Epidural Analgesia (PCEA) – If an epidural is placed for post-op pain and is not the...

The United States Supreme Court allocated more time to oral argument on the constitutionality of the Affordable Care Act (ACA) last week than it had to any other case in the past 50 years.  Four distinct questions were before the Court during six hours of argument spread over three days.  In chronological order of consideration, these questions were: Does the 1867 Anti-Injunction Act, which bars pre-enforcement litigation over a tax, prevent the Court from hearing the challenge to the insurance mandate? Can Congress compel individuals to buy insurance or pay a penalty (the “individual mandate”)? Can the rest of the ACA survive if the individual mandate is struck down? Can Congress pressure states to expand Medicaid coverage by threatening to withhold funds?The Individual MandateThe room was packed and buzzing with excitement.  Some people clearly had slept outside last night.  Even some of the attorneys general from the challenger states had to...

From time to time anesthesia groups find that they need to reassess their administration or decision-making processes. This can involve everything from tinkering with how routine day-to-day administrative activities are carried out, to totally revamping the group’s governance structure.Reassessments can come about for a variety of reasons. There may have been a significant growth in the number of physicians or CRNAs, or an increase in the number of practice locations. The group may have encountered internal strife without adequate governance systems in place. The group may find itself incapable of making decisions or reaching consensus in a timely or efficient manner. A group may have relied too heavily upon busy physicians to carry out non-clinical duties, or one physician may (by choice or otherwise) be overburdened with administrative responsibilities.Issues in a Small Group. One of the assumed advantages of a smaller group is that it can function in a “more efficient” manner....

Anesthesia is the quintessential service specialty. Establishing and maintaining a consistently strong  relationship with a hospital, a clinic or an ASC is no easier for an anesthesia group practice than for any other type of service provider, be it car mechanic, internet provider or hair stylist; today’s medical consumers know they have options that give them leverage in demanding services and loyalty. For too many anesthesia practices this is a relatively new and somewhat disconcerting state of affairs. Anesthesia vulnerability to replacement has grown in direct proportion to the amount of financial support provided by the facility; practices that receive no subsidy support clearly have the strongest support, at least to the extent that they provide quality care. Competition for anesthesia contracts has ushered in a new era of service expectations and changed the perception of the role of the specialty in the facility. Quite simply consistently good outcomes are simply...

WHY FEDERAL INSURANCE REGULATION?Normally, insurance companies are regulated by the states. As a result there are hundreds of statutes and rules affecting companies that operate in multiple states. The National Association of Insurance ComNAIC, missioners (NAIC) issues guidance to standardize insurance laws, but states are not required to follow its recommendations. As might be expected this results in increased costs as companies design multiple products to comply with diverse and sometimes conflicting state regulations and formalities.For the most part the Federal Government has not interfered in state insurance laws, leaving the regulation of the industry to state regulators. Non interference has worked adequately during soft markets in which insurance is easy to find.IMPACT OF A “HARD MARKET”During “hard” markets in which insurance coverage is difficult to obtain, the federal government has stepped in to allow an insurance company to operate in many states as long as one state agrees to license...

On August 22, 2011, as a result of a directive from President Obama, the US Department of Health and Human Services (“HHS”) issued its Plan for Retrospective Review of Existing Rules (“Plan”). The Plan includes a review from all HHS operating and staff divisions (e.g., the Centers for Medicare and Medicaid Services (“CMS”)) that establish, administer and/or enforce regulation. HHS’ Plan aims to review “existing significant regulations to identify those rules that can be eliminated as obsolete, unnecessary, burdensome, or counterproductive or that can be modified to be more effective, efficient, flexible, and streamlined.” While, on its face, a review of unnecessary regulations appears to be beneficial, looking below the surface reveals that the review may create fundamental changes in medical and anesthesia practice. CMS is contemplating reviewing the conditions of participation (“CoPs”) for anesthesia services (42 CFR 482.52) to eliminate the certified registered nurse anesthetist (“CRNA”) supervision requirement, which could...