Over the New Year holiday, Congress finally passed legislation to stop the U.S. economy from going over the fiscal cliff. The new law included a temporary reprieve from the 26.5 percent cut provided for by the Medicare Sustainable Growth Rate (SGR) formula. There will be no SGR reduction throughout 2013—a development that lets us all breathe a deep sigh of relief, even though the formula itself, and its future depredations, are still in the law. Medicare payments to physicians and hospitals are not inviolate for the coming year, it must be noted: automatic two-percent reductions will hit Medicare as part of the “sequestration” process just two months from now if Congress and the White House do not reach another deal. For many anesthesia practices, the runup to negotiations with hospitals and payers is a cliffhanger—indeed, even contemplating future negotiations often feels precarious. Last year, one of the national anesthesia practice management...

In meetings and conferences where the presenter asks anesthesiologists and pain physicians whether they are participating in—or negotiating with—an Accountable Care Organization (ACO), very few, if any, of the doctors raise their hands.  Everyone is aware of the concept of ACOs, but almost no one has any experience with them yet.  Nevertheless, there are significant ACO developments across the country.Tens of millions of patients are already receiving medical services through ACOs. A year ago—even before the United States Supreme Court’s decision upholding most of the Affordable Care Act—32 ACOs were participating in the Medicare Pioneer demonstration program  and 27 more had signed up to become Medicare ACOs.  Becker’s Hospital Review briefly described 80 Accountable Care Organizations to Know, both commercial and Medicare, in an online article dated April 16, 2012.  Many of these ACOs were formed by hospitals and health systems in partnership with health plans.  They range in size from as...

  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...

CMS’ Medicare Recovery Audit Contractor (RAC) Program has now been in effect in all 50 states for three years.  The RACs, readers will recall, are contractors who are compensated on a contingency fee basis for finding and recouping overpayments made by Medicare to physicians, hospitals and other providers.  Each of the four RACs is responsible for identifying overpayments—and underpayments—“in a geographically defined area that is roughly one-quarter of the country. In addition, [they] are responsible for highlighting to CMS common billing errors, trends, and other Medicare payment issues,” according to a report from CMS to Congress released earlier this month and entitled Recovery Auditing in the Medicare and Medicaid Programs.The RACs analyze Medicare FFS claims on a post-payment basis, using three different processes: (1) automated reviews of claims data, (2) semi-automated reviews where the RAC allows the provider to substantiate the claim with supporting documents and (3) complex reviews, where a qualified...

  Part I of this survey (Alabama-Missouri) appeared in the Fall 2012 issue of the Communiqué. In Part II, we summarize the laws and regulations that require health plans to pay claims within a given period in the remaining states (Montana-Wyoming), as well as the penalties for violations.