Further Clarification of eRx Penalty and Hardship ExemptionThe Medicare eRx Incentive Program is turning out to be the Full Employment for Healthcare Writers program.  Last week we described how anesthesiologists, pain physicians and nurse anesthetists with prescribing privileges could apply for a hardship exemption using a new CMS web page, the Communication Support Page.   “Most anesthesiologists … will not qualify for either the eRx bonus or the eRx penalty because they submit very few electronic prescriptions and report very few of the outpatient visits encompassed by the eRx measure.”We would like to reemphasize this point.  Anesthesiologists are not subject to any eRx penalty this year if they did not:Submit claims to Medicare for at least 100 outpatient or office visits, for dates of service between January 1, 2011 and June 30, 2011.  Only those evaluation and management services identified by one of the CPT™ codes in the measure specification (including codes 99201,...

Medicare’s Value-Based Purchasing (VBP) program for hospitals, mandated by the Affordable Care Act, took off upon the release of final regulations on April 29, 2011.  VBP marks the start of true pay-for-performance, as opposed to pay-for-reporting, at the hospital level. The intent is to pay for better value, patient outcomes and innovations, and not simply to reward volume of services.  As we enter 2012, we are halfway through the first performance period.  Anesthesiologists should begin analyzing and planning how they might partner with their hospitals in achieving the scores necessary to earn VBP incentives.The hospital scores are based on Clinical Process of Care measures (70%) and on Patient Experience of Care (30%) as measured by completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.  Hospitals receive points for achievement and improvement for each measure in the two domains, with the greater set of points counting toward the domain total....

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 change to some language in the Anesthesia Services chapter of the Medicare National Correct Coding Initiative (NCCI) manual recently created considerable confusion among participants in the on-line discussion maintained by the Medical Group Management Association (MGMA) for the Anesthesia Administration Assembly (AAA).The information that gave rise to the confusion has been clarified.  The NCCI has confirmed that there has been no policy change here; epidurals and blocks placed preoperatively for the management of postoperative pain are still separately reportable and not bundled into the anesthesia service unless they are used as the method of administering the anesthesia itself. Because the issue of post-op pain management is a perennial hot topic, we take this opportunity to help ensure that no incorrect interpretations take root.Chapter II of the NCCI manual, “Anesthesia Services,” was revised effective January 1, 2012.  It contains a number of statements that are consistent with the established principles of billing...

Anesthesia Business Consultants' (ABC) dedication to the complex and intricate specialty of anesthesia and pain management requires continued commitment to technology and collaboration with the technology leaders in the industry.  ABC and Picis are pleased to announce a strategic partnership to leverage the combined strengths of technology and operations to all facets of the anesthesia community.  Anesthesiologists, along with the hospitals and ASCs they serve, continually evaluate their technology partners and how to best utilize the value they contain.  By the joint efforts of ABC and Picis, we enable our mutual customers with a streamlined process for billing and bring the confidence of a combined effort to the ever-increasing pressures extended by payers, patients, and regulatory bodies. The Best Partnerships Strengthen Business Processes As the nation’s largest billing and practice management company in the specialty field of anesthesia and pain management, we distinguish ourselves by providing optimal business tools to strengthen...

Owners of ambulatory surgical centers (ASCs) often wish to receive a share of the professional fees paid to their anesthesiologists and nurse anesthetists.  ASC owners and anesthesiologists and CRNAs have adopted—or at least proposed—numerous corporate and contractual structures over the last few decades to accomplish this transfer of revenues.  The federal Anti-Kickback Statute (AKS), which prohibits a broad range of payments for referrals, has generally caused conservative lawyers to advise against such arrangements.  Some attorneys and other advisors who are less risk-averse have helped their clients to go ahead. The HHS Office of the Inspector General (OIG) has just provided some guidance on the issue.  The guidance takes the form of an Advisory Opinion (No. 12-06) (posted June 1, 2012), which means that the decision is not binding on any parties, including the OIG.  Nevertheless, the Advisory Opinion spells out how the OIG would apply the AKS principles to two common...

Inspector General Daniel Levinson of the Department of Health and Human Services has stated in his Spring 2012 Semiannual Report to Congress that his office expects to recover $1.2 billion from audits ($483 million) and investigations ($748 million) concluded during the first half of 2012.  Between October 2011 and March of this year, the OIG also brought 346 new criminal cases and 138 civil actions. Information technology is playing as important a role in the OIG as it is in every other health care arena.  In his Executive Summary, Mr. Levinson said: Over the past 6 months, OIG has stepped up our focus on data analytics as a critical tool for enhancing our fraud, waste, and abuse activities. We are using advanced data analytics to help us conduct risk assessments; more effectively pinpoint our oversight efforts; and significantly reduce the time and resources required for audits, investigations, evaluations, and other program...

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...

Wow, what a day! You've just left a meeting with the hospital's CEO. Of the fifteen anesthesiologists in your openstaffed department, the CEO wants you to be the new, first medical director of anesthesia services. You've been the department's chair for the past two years, but now you've been offered an administrative stipend of $2,500 a month. It doesn't appear to be any more work than what you've been doing, and the $2,500 is more than you need for the payments on a new Porsche!Just as you feel your grip on the steering wheel, the alarm clock jars you awake. Should you savor the memory . . . or be thankful that it was only a nightmare?DREAM ANALYSIS 101Relax. Put your feet up. In order to analyze the dream, we need to back up a bit and consider the operation of an anesthesia department, as an element of the medical staff,...

Patient AB underwent a rotator cuff reconstruction in January, more than four months ago.  You billed the health plan that Mr. AB’s hospital record indicated.  The health plan denied the claim on the ground that Mr. AB was not enrolled.  You then billed Mr. AB directly for $1072.50 your usual and customary charges for anesthesia for a 120-minute open procedure on the shoulder joint (CPT™ code 01630, 15 units x $75 conversion factor) and an epidural for post-operative pain (CPT™ code 64415, $97.50).  You re-billed the patient in March, in April and again on May 15th.  Your billing office reached Mr. AB on the telephone on May 16th and was told that (1) his insurance was supposed to cover everything, (2) no one had told him to expect a bill for anesthesia separate from the hospital and surgeon statements and (3) he was now unemployed and did not have the money. ...

Abby Pendleton, Esq., The Health Law Partners, P.C., Southfield, MIStephanie P. Ottenwess, Esq., The Health Law Partners, P.C., Los Angeles, CAOn March 7, 2012, the Centers for Medicare and Medicaid Services (CMS) published its Notice of Proposed Rule Making (NPRM, or proposed rule) for Stage 2 user requirements for the Medicare/Medicaid Electronic Health Record (EHR) Incentive Program (“meaningful use,” or MU) in the Federal Register. 77 FR 13698.1 There is a three pronged focus to the Stage 2 criteria: standardizing data formats to dramatically simplify how information is both captured and shared across disparate IT systems in order to be better able to coordinate care with other physicians; ensuring that patients be able to access and easily download their healthcare records and images for their own use; and expanding the scope of tracked quality metrics to include specialists and to reflect and improve specific patient outcomes as well as care coordination.Although subsequent to...

“Coordinated care” is one of the key concepts in health system reform.  It is central to the cost savings and quality improvements expected from Accountable Care Organizations, value-based purchasing and the medical home.  It is also the basis of the American Society of Anesthesiologists’ model, the perioperative surgical home.A just-published study demonstrates the potential of coordinated management of patients, inter alia, to reduce complications in knee replacement surgery.  A research team from the High Value Healthcare Collaborative used administrative data to examine differences in their delivery of primary total knee replacement (TKR) care.  They reported their findings in A Collaborative Of Leading Health Systems Finds Wide Variations In Total Knee Replacement Delivery And Takes Steps To Improve Value (Ivan M. Tomek, Allison L. Sabel, Mark I. Froimson, George Muschler, David S. Jevsevar, Karl M. Koenig, David G. Lewallen, James M. Naessens, Lucy A. Savitz, James L. Westrich, William B. Weeks, and James N....

Anesthesia Business Consultants, LLC (ABC) embraced a new role and filed formal comments on a “Notice of Proposed Rulemaking” with the Centers for Medicare and Medicaid Services (CMS) on May 7, 2012.  The Proposed Rule would modify the requirements for physicians and hospitals to demonstrate “meaningful use” of certified Electronic Health Record (EHR) technology.  Meaningful users of certified EHRs are able to earn Medicare bonuses of up to $44,000 or Medicaid bonuses of up to $63,750 per physician.  Just as important, eligible professionals who fail to become meaningful users  will be subject to payment penalties beginning in 2015. Even with the best of intentions and a reasonable amount of funds to invest, very few, if any, anesthesiologists can qualify for the bonus incentives—but they may nevertheless be subject to the penalties.  To earn the former and avoid the latter, a physician must comply with a set of 15 (17 in Stage...

The Affordable Care Act (ACA) requires providers including physicians to report and refund known overpayments within 60 days, or, for providers that submit cost reports, by the date the corresponding cost report is due.  The parameters of this mandate are unclear, but the duty to refund overpayments exists regardless.  After summarizing some of the problems with the ACA provision and with CMS’ proposed regulations implementing the statute, we will offer some practical suggestions on compliance.The refund requirement, which has been in effect since March 23, 2010 (the date the ACA became law), is vague in several important particulars.  The lack of certainty, far from discouraging compliance, has left many providers, suppliers and affected health plans scrambling to find and refund overpayments within the 60-day window to avoid hefty penalties.  On February 16, 2012, CMS issued a proposed rule that limited its application to Medicare payments and cleared up some, but not...

The Anesthesia Quality Institute was chartered in 2009, and it began collecting case data in the National Anesthesia Clinical Outcome Registry (NACOR) on January 1, 2010. NACOR was designed to harness the power of the Information Age by aggregating and analyzing large quantities of data. Unlike traditional registries that depend on a trained abstractor to examine medical records and pull out the facts of interest, NACOR accumulates data by direct reporting from the electronic health records (EHR) that are in use every day, including administrative systems such as the ABC billing software and clinical support systems such as ePreop. As anesthesia practices become increasingly digital — driven by the “meaningful use” requirements of the federal government discussed elsewhere in this issue of the Communiqué — even larger quantities and types of data will be available. The barrier is no longer the creation of digital records; it is now the enormous challenge...

Do you check your professional association’s web site regularly?  There is more practice-related information there than you may realize.  One recent addition to the resources on the American Society of Anesthesiologists web site (www.asahq.org) is worth your special attention.  The ASA Committee on Quality Management and Departmental Administration (QMDA) has produced a comprehensive set of questions for anesthesiologists and others involved in perioperative patient care that can guide the development of a quality program tailored to your own department.The QMDA Anesthesiology Department Quality Checklist is a “compendium of anesthesia safety and quality measures suitable as a reference for anesthesiology departments of any size as they develop a comprehensive set of quality standards.”  It consists of separate sets of questions for these individuals and offices:Chair of AnesthesiaStaff AnesthesiologistSurgeonCRNA and/or AA Perioperative Nursing ManagerOperating Room NursePACU Nursing ManagerObstetric Nursing ManagerQuality ManagementAdministrationAnesthesia Technicianas well as for Office Based Anesthesia Facilities.  The questions, and the answers received, can...

Every year, the time comes to begin looking at one or a set of payor contracts. A multitude of questions abound regarding appropriate rates, term length, and whether or not to participate or stay on panel. These are all good questions to raise. But are these the only questions to ask? This article seeks to explore the value of planning for payor negotiations.As a backdrop to the planning, it is important to remember the value of strategic planning as described by Sun Tzu:The general who wins a battle makes many calculations in his temple where the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat: how much more no calculation at all! It is by attention to this point that I can foresee who is likely to win or lose.1The point is primarily 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...

While the eventual fate of the Patient Protection Affordable Care Act (PPACA) will be decided in the near future, by either the Supreme Court or the next Congress and Administration, what is not open for debate is that healthcare has changed. As the business of medicine evolves to accommodate the changes called for in the healthcare reform laws, so should anesthesiologists anticipate their place in the new environment. The physician group that is able to make informed decisions will be best positioned to evolve and thrive in this era of change. Just like the old Saturday morning cartoon said, “Knowledge Is Power”; by gathering, understanding and responding to information, anesthesiologists can be certain to meet the needs of their clients and proactively position themselves as a catalyst for change.One way of taking that proactive step is to use data to help shine a light on the inner workings of your anesthesia...