A Change in the Wind: New Policy Further Complicates Anesthesia Practices
You just know it when it happens. It is that sudden shift in events that eerily presages a change in one's fortunes—and not necessarily for the better.
For decades now, anesthesia practices have been able to rely on certain unchanging rules when it comes to the reimbursement of the providers' services. This includes those groups that utilize certified registered nurse anesthetists (CRNAs). For the most part, payers have followed Medicare's lead in reimbursing CRNA services at the same level as the anesthesiologist. While there is the occasional odd outlier, this equality of payment has been the industry norm. That may be coming to an end.
The Revision
Beginning this month, one of America's major health insurance companies will be making a change in its reimbursement policy relative to CRNAs. Health giant Cigna recently published a bulletin in which they outlined modifications to their anesthesia policy. In this bulletin, Cigna announced its intention to lower CRNA reimbursement on claims submitted with the QZ modifier (indicating a non-medically directed CRNA service). This new payment policy will apply to dates of service on or after March 12, 2023. Here is the wording of the bulletin:
Modifier QZ Reimbursement for CRNA Services
We will reduce reimbursement for claims submitted with modifier QZ for services rendered by a certified registered nurse anesthetist (CRNA) by 15 percent. Denials will include administrative appeal rights. We will update the Healthcare Common Procedure Coding System (HCPCS) National Level II Modifiers reimbursement policy to reflect this change. This update aligns with our reimbursement rate for advanced practice providers.
That reference to an alignment with reimbursement rates for other advanced practice providers (APPs) is another way of saying that the QZ rate is now set at 85 percent of the allowable for Cigna cases—just as other non-physician practitioners (NPPs) are typically reimbursed at 85 percent of the allowable, as compared to 100 percent for physicians.
The Rationale
One may wonder at this point why Cigna would be making such a major policy shift at this juncture. The rationale for these modifications, according to the carrier, was based upon an array of considerations. According to the Cigna bulletin:
We routinely review our coverage, reimbursement, and administrative ·policies for potential updates. ln that review, we take into consideration one or more of the following:
The bulletin then proceeds to provide a list of sources that the carrier believes lend support to its new reimbursement policy. The sources listed are as follows:
- ● Evidence-based medicine (EBM)
- ● Professional society recommendations
- ● Centers for Medicare & Medicaid Services (CMS) guidance
- ● Industry standards
- ● Our other existing policies
It is uncertain how the payer determined to change its long-standing payment practices based on the above sources. Clearly, Medicare calls for the 100 percent payment rate in QZ cases, and this is the industry standard, as well. The other sources listed are not particularly determinative as there is no uniformity among the studies (EBM) and the professional societies in this regard. On the whole, Cigna's decision seems to be a bit arbitrary and clearly runs counter to the way QZ services are reimbursed across the payer spectrum.
The Ramifications
Clearly, this is a game-changer. At least as it pertains to those groups that employ CRNAs, this is going to mean less revenue. Obviously, the extent to which this plays out will depend on how significant Cigna cases are within your payer mix and the way in which CRNAs are utilized in your practice. As a point of clarification, this Cigna policy announcement only applies to CRNA cases where the QZ modifier is appended to the anesthesia code on the claim form. It does not apply to CRNA claims that have the QX modifier, meaning the CRNA is being medically directed. On such cases, the CRNA will still receive the 50 percent of the allowable, with the medically directing anesthesiologist receiving the other 50 percent, for a total of 100 percent on the case.
Even where the group model is medical direction, there may be a few cases where the anesthesiologist fails to make it back for emergence, for example. In such cases, the CRNA can typically bill out the case with the QZ modifier. The problem is that, now, with Cigna patients, this means less revenue for those cases. For those practices that have a collaborative model, where all CRNA cases are non-medically directed, this new policy will obviously have a greater financial impact. Because of this, such groups may need to seriously consider moving to a medical direction model.
The greater ramification from the Cigna announcement is the possibility of contagion. While there may be a few minor or regional health plans that already reimburse CRNA services at the 85 percent rate, this appears to be the first time we've seen a major national health insurance company impose such a position. Serious policy divergences from a major player in the market, such as Cigna, may have the effect of causing other significant health plans to be more willing to consider a similar policy change. And, just like that, we could see several national payers break with the established norms and possibly head down this same path. We will have to keep an eye on these developments to determine if this current change in the wind is only a momentary breeze or an unstoppable gale. If you have questions about how the Cigna policy change could impact your practice, please contact your account executive. You can also reach us at info@anesthesialllc.com.