Patients who go out of network can present serious collections problems for the physicians who do not participate in the network.   Managed care organizations (MCOs) often send the check to the patient in order to pressure physicians to sign participation agreements, leading to the necessity for practices to collect directly from the patients, something that is especially challenging for hospital-based anesthesiologists and other physicians who do not have ongoing relationships with their patients.MCOs do not like patients going out of network either, and increasingly some payers are going to extreme lengths to discourage that behavior. The efforts of one such payer, Aetna Health of California, Inc., to limit the use of out of network services recently led to the filing of a lawsuit.  On July 3, 2012, the California Medical Association (CMA), three county medical societies, and a coalition of four surgery centers and 60 physicians and one unidentified patient brought an...

The Supreme Court’s decision on the fate of the Patient Protection and Affordable Care Act (PPACA or, more commonly, ACA) is due to be announced at 10:15 on Thursday morning, June 28.  We are not jumping the gun by beginning to write this Alert ahead of the decision – the take-away message is that whether the ACA stands or falls, in whole or in part, anesthesiologists need to continue developing their role in perioperative care.Towards the Perioperative Surgical Home™ Model of CareCoordinated medical care is now an established value and goal in both the public and private sectors.  “Silos” and “fragmentation” are pejorative terms used to describe the type of health care delivery system that policymakers seek to leave behind. Many anesthesiologists began expanding their role in coordinating perioperative care long before the ACA was written, in pre-anesthesia testing through post-operative pain medicine services.  Several years ago, the American Society of Anesthesiologists...

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...

The EHR Incentive Program, often dubbed “Meaningful Use” (MU), has been surrounded by questions and confusion among anesthesiologists and practice administrators since its inception.  Currently, the majority of anesthesiologists and pain physicians are classified as an Eligible Professional (EP) under the Medicare portion of Meaningful Use and most of the public conversation is centered on that program.  However, the Medicaid option offers more flexibility and financial incentive which raises the question, “How does the Medicaid EHR Incentive Program differ from the Medicare portion?”  The major differences between the Medicare and Medicaid programs of Meaningful Use center on:Provider EligibilityProvider EnrollmentFinancial IncentiveAttestation ScheduleProvider Enrollment and Eligibility To be considered a Medicaid EP, an anesthesiologist or pain physician must perform less than 90% of their services in an inpatient setting (POS 21), but also must provide at least 30% of services to Medicaid patients.  According to CMS: Medicaid patients might be fee-for-service encounters where...

This issue of the Communiqué is a keeper. On pages 6 through 10 you will find tables that lay out clearly the Electronic Health Records (EHR) incentive program’s Stage 1 Meaningful Use objectives, the recently proposed changes to Stage 1, and the potential Stage 2 objectives, measures and exclusions as proposed by CMS in March. The objectives, translated into measures, are capabilities that your EHR must have in order for you to qualify for the incentive, which is non-negligible at a maximum of $44,000 per physician, or to avoid the penalty for non-compliance. Even though the proposed changes discussed in the Meaningful Use article by Abby Pendleton, Esq. and Stephanie Ottenweis, Esq. are likely to be different in some respects when CMS issues the final regulation later in the year, it is worth familiarizing yourself with the proposals because understanding the final versions will be that much easier.The Meaningful Use article,...

  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....

Please take a moment to participate in the second annual ASA nationwide survey on anesthesia drug shortages. This brief survey will help ASA continue to work with legislative and regulatory policymakers to develop policies that help to avert drug shortages, provide advanced notification and mitigate the effects of drug shortages. Data from last year's survey was instrumental to ASA in demonstrating the urgency of addressing drug shortages.      For this survey to be successful, ASA will again need a high participation rate of members.  Please complete this survey and encourage other ASA members to do so as well. http://www.surveymonkey.com/s/asadrugshortagesurvey I. Revised Anesthesia Conversion Factors CMS has just updated the Medicare conversion factors (CFs) for anesthesia services.  The new national, unadjusted CF is $21.52, up from $21.41 for the first two months of 2012.  Download the list of locality-adjusted CFs here. As noted on the CMS website, “Medicare payment rates under...

For the last several months the literature on Accountable Care Organizations (ACOs) has flourished. So has the volume of workshops, seminars and webinars, all with the intent of educating providers on what the future will look like, and many addressing how physicians might participate. Independent anesthesia groups are trying to not only understand the ACO rules but are also working hard to determine how they will function in any of the possible structures that emerge in their communities.There are various traditional obstacles to the formation of multispecialty groups, such as those posed by the antitrust and antikickback laws.    The Patient Protection and Affordable Health Care Act calls upon the Secretary of Health and Human Services (HHS) to adopt regulations that will foster the development of ACOs, and that includes resolving potential conflicts between the antitrust, antikickback and Stark laws and the efficiencies expected to result from the formation of ACOs.Given that...

In any financial transaction, the person holding the money is at an advantage.  Getting money back from someone who should not have been paid is harder than not making the payment in the first place.   CMS knows this, and that is why it is placing a new emphasis on prepayment review of claims.  Originally slated to begin on January 1, 2012 the prepayment review initiative will now formally launch in June.  The number of prepayment reviews is going to increase from 1.2 million to 2.7 million claims per year. There is a large amount of taxpayer dollars at stake.  In 2011, the Medicare fee-for-service improper payment rate was 8.6 percent, or $28.8 billion in estimated erroneous claims payments.  Medicaid adds another $21.9 billion.  During 2011, CMS recovered $5.6 billion in fraudulent payments, an increase of 167 percent over 2008. The increase in recoveries is attributable in major part to the $350...

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...