Most practicing anesthesiologists know that the federal anti-kickback statute prohibits hospitals, ambulatory surgical centers and others from asking for something of value in exchange for the referral of patients for anesthesia services.  Paying for the anesthesia franchise violates the statute.  So does soliciting payment for the franchise. As simple as this general principle would seem, the Department of Health and Human Services Office of the Inspector General (OIG) periodically finds it necessary to spell out the parameters again.  Most recently, anesthesiologists who had an exclusive hospital contract requested and received an advisory opinion (No. 13-15)  from the OIG stating that a proposed arrangement involving reassignment of fees to a psychiatry group and a per diem payment to the anesthesiologists “could potentially generate prohibited remuneration under the anti-kickback statute and that the OIG could potentially impose administrative sanctions."  In other words, the parties would proceed with the arrangement only at their peril. The...

Attorneys in various specialties are always keeping an eye out for outgoing, charismatic, smart physicians willing to provide expert testimony. Common cases in need of expert testimony include medical malpractice, personal injury, wrongful death and auto accidents. Testifying as an expert witness requires qualifications that vary from state to state. Whether you have never testified as an expert witness, or testify routinely, this article will outline some considerations to keep in mind when providing (or deciding whether to provide) expert testimony. What it Means to Serve as an Expert You may be approached to provide expert testimony as a treating physician, or in your capacity generally as an anesthesiologist or pain management specialist in a case with which you were not involved. Sometimes, the testimony of an anesthesiologist or pain management specialist will be requested simply to explain the treatment rendered to a patient. For example, if a patient was involved...

The Centers for Medicare and Medicaid Services (CMS) does not conjure up the relative value units (RVUs) on which payment for individual procedures is based, although it may sometimes seem that way.  A consensus group of physicians representing all the major specialties, convened by the American Medical Association (AMA), meets three times a year to develop recommendations for RVU adjustments. The recommendations from the consensus group (the Relative Value Scale Update Committee, or RUC) are sent on to CMS, which considers the information as it prepares its annual update to the Physician Fee Schedule. In recent years, CMS has adopted between 87.4 and 95 percent of the RUC’s recommendations, depending on which source you accept, Health Affairs or the RUC, respectively.  The former figure represents 2,419 out of 2,768 recommendations that the RUC proposed between 1994 and 2010.Composition of the RUCThe RUC consists of 31 members, 28 of whom are eligible...

Webinar for Anesthesia Providers on the ICD-10 ConversionAre You Ready for ICD-10? The Impact on Coding & BillingWednesday, November 20, 2013 at 5:00 p.m. ESTLess than one year from now, the implementation of ICD-10 will impact anesthesia and pain medicine practices across the country. According to CMS, “On October 1, 2014, the ICD-9 code sets used to report medical diagnosis and inpatient procedures will be replaced by ICD-10 code sets.  The transition to ICD-10 is required for everyone covered by HIPAA.”  The delay in implementation by one year gave payors, vendors and practices time to prepare, yet the question to be answered is “Are You Ready for ICD-10?”Anesthesia Business Consultants is offering all interested parties an opportunity to attend an educational webinar on the topic. Darlene Helmer, CMA, CPC, ACS-AN, CMPE, MBA, ABC’s Vice President for Provider Education and Training, will discuss the steps that anesthesia providers should consider taking to...

Most anesthesiology practices provide services in ambulatory surgical centers (ASCs), and quite a few anesthesiologists have investment interests in ASCs.  With more than 5,400 Medicare-certified ASCs in the United States, 1.8 percent more than in 2012, a look at the characteristics of successful facilities and at the challenges they face should be worthwhile. Meeting the marketplace challenges is the foundation of success.  Topping the list of challenges for ASCs today, now that the implementation of the Affordable Care Act is underway, are the following: Attracting and retaining surgeons and other physicians who will contribute to the facility’s bottom line.  Securing coverage, high quality and a referral base have always been key, but as more and more physicians opt for hospital employment, the pool of unaffiliated physicians is shrinking.  More than half of new physicians are taking jobs with hospitals rather than entering private practice.  Twenty-nine percent of physicians were working directly...

    Securing the Future for Anesthesia PracticesAs the health care world continues to evolve, offering new technological advances and business models, along with changing laws and regulations, it’s imperative to keep informed. Anesthesiologists, Practice Administrators, CRNAs and others in the anesthesia marketplace now have a great new option when looking to attend a conference on anesthesia practice management:  The Advanced Institute for Anesthesia Practice Management.The Advanced Institute for Anesthesia Practice Management is an exciting new conference with new sponsors and a fabulous new venue. Previously known as the Anesthesia Billing & Practice Management Seminar, this new name reflects our commitment to position our conference as the premier educational opportunity for decision makers of anesthesia practices, including Anesthesiologists and Practice Administrators. The conference will take place at the hottest property on the Las Vegas Strip, The Cosmopolitan of Las Vegas, from April 11-13, 2014.The Advanced Institute for Anesthesia Practice Management offers the...

Last spring, we alerted readers to a proposed payment policy (“Local Coverage Determination,” or “LCD”) under which Noridian Administrative Services, LLC, the Medicare Administrative Contractor (“MAC”) for nine Western states, would have denied coverage for blocks and epidurals placed pre-operatively for the management of post-operative pain.  In Proposed "Medical Necessity" Restrictions on Post-Anesthesia Pain Blocks, we criticized the proposed LCD for confusing the timing and the purpose of post-operative pain procedures and explained the process by which MACs propose, revise and finalize LCDs.  We encouraged readers to use the process, and their representatives on the Carrier Advisory Committees of practicing physicians, to speak up for patients and help prevent undue restrictions on the availability of post-operative pain management services. Unfortunately, although Noridian quickly corrected the section of the proposed LCD on “Nerve Blockade: Somatic, Selective Nerve Root, and Epidural” that would have prevented payment to anesthesiologists for performing procedures before or...

CMS defines surgical anesthesia time as “the continuous, actual presence of a qualified anesthesia provider. This time begins when the anesthesia provider begins preparing the patient for anesthesia in the operating room or equivalent area. Anesthesia time ends when the anesthesia provider is no longer in personal attendance.” The ASA Relative Value Guide has a similar definition: “anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the patient is safely placed under post-anesthesia supervision.” This is a typical “clear as mud” definition when it comes to anesthesia and CMS. Exactly what is an equivalent area? Is this “equivalent area” ambiguity something we can use to our advantage or is it a disadvantage? Could it be both? It all depends on how or who does the interpretation of the anesthesia record; nevertheless, as long as...

As both colonoscopy rates and use of anesthesia during gastrointestinal endoscopies are projected to increase in the coming years, the overall cost of colonoscopy screening programs will be closely scrutinized by payers and policy makers. Liu, Waxman, Main and Mattke made the quoted prediction in their article Utilization of Anesthesia Services During Outpatient Endoscopies and Colonoscopies and Associated Spending in 2003-2009 (JAMA. 2012;307(11):1178-1184).  This study involved a retrospective analysis of claims data for a 5% representative sample of Medicare fee-for-service patients (1.1 million adults) and a sample of 5.5 million commercially insured patients during the six year period 2003-2009.  The authors determined that overall, the proportion of anesthesia services delivered to low-risk (ASA physical status 1 or 2) patients was more than two-thirds in the Medicare population, and more than three-quarters among the commercially insured population.  Over the six-year period, annual payments for anesthesia services among Medicare patients almost doubled in...

  Attorneys in various specialties are always keeping an eye out for outgoing, charismatic, smart physicians willing to provide expert testimony. Common cases in need of expert testimony include medical malpractice, personal injury, wrongful death and auto accidents. Testifying as an expert witness requires qualifications that vary from state to state. Whether you have never testified as an expert witness, or testify routinely, this article will outline some considerations to keep in mind when providing (or deciding whether to provide) expert testimony. What it Means to Serve as an Expert You may be approached to provide expert testimony as a treating physician, or in your capacity generally as an anesthesiologist or pain management specialist in a case with which you were not involved. Sometimes, the testimony of an anesthesiologist or pain management specialist will be requested simply to explain the treatment rendered to a patient. For example, if a patient was...

The anesthesia community is rich in practice management educational resources. And now there is a new opportunity: The Advanced Institute for Anesthesia Practice Management. ABC, together with Medical Business Solutions and the Center for Continuing Education, Tulane University Health Sciences Center, is co-sponsoring the Advanced Institute for Anesthesia Practice Management (AIAPM).

The latest court decision in the eight-year whistleblower litigation against Tuomey Healthcare System in Sumter, South Carolina, giving rise to perhaps the largest amount of damages—$276,767,260—ever awarded against a community hospital, provides an opportunity to review some Stark law.  The September 30 order and opinion from the federal district court also demonstrates some compliance strategies to be avoided, notably shopping around for the most obliging legal advice. Tuomey was faced, in 2003, with a new, competing ambulatory surgical center (ASC).  Fearing that it would lose cases to the ASC, the hospital entered into employment contracts with 19 surgeons and gastroenterologists.  The contracts contained the following terms: Part-time employment covering only outpatient procedures, which the physician was required to perform at Tuomey facilities; Initial salary based on the previous year’s collections; Productivity bonus of 80% of collections; Incentive bonus of up to 7% of productivity bonus; All malpractice premiums (not just for...

The most authoritative information on managed care (commercial) contract rates for anesthesia services has just been updated.  The ASA Survey Results for Commercial Fees Paid for Anesthesia Services -2013 appears in the October issue of the ASA Newsletter. The national average managed care contractual conversion factor (CF) was $71.69, based on valid responses from 223 practices in 44 states and Washington, D.C.  This represents a 5.52% difference over the comparable figure for 2012, $67.94. Because of the way the survey responses are leveraged and the data reported, however, we caution against assuming that contract increases have averaged more than five percent.  The “national average managed care contractual CF” is an average of averages.  The survey requests CFs for five of each group’s largest managed care contracts, along with the percentage of their commercially-insured patient population that each contract represents.  This permits ASA to report means and percentiles for the contracts representing...

This post was written by: Aman Mahajan, MD Chair, Department of Anesthesiology, University of California, Los Angeles, CA Jody Locke, CPC Vice President of Anesthesia and Pain Management Services, ABC Background It is often suggested that an anesthesiology department should have more complete and readily accessible data about the clinical care provided in the operating rooms and the delivery suite than any other department of the facility; but how often is this actually the case? Anesthesia providers review and document enormous amounts of clinical detail and critical events for every patient they see, but little of this information is actually captured in a way that allows for its logical indexing and retrieval. Most anesthesia groups and their billing services have been so focused on the data necessary to calculate a charge and generate a claim that they have virtually ignored what is potentially the most valuable of information of all. The...

With the ICD-10-CM conversion deadline one year away, many professional organizations and industry experts are warning of a lack of preparation and the serious adverse effects on practice revenues.  The level of alarm and doom is not realistic nor a given outcome for the majority of anesthesiologists.  With reasonable physician diligence in documenting services completely and accurately, successful conversion is likely.  Groups should make sure that their billing companies are preparing them to meet the new documentation requirements—as ABC will do—to avoid claim processing delays or denials beginning on October 1, 2014. We want to reassure all anesthesiologists, including our clients, that the proverbial sky is not going to fall come October 1, 2014.  Let us start with a review of the facts: What is it? Beginning October 1, 2014, all health care entities must use ICD-10 codes on claim forms. This includes: Diagnosis codes (ICD-10-CM) used by all providers in...

The decisions that anesthesiologists and pain medicine specialists must make are more fundamental and consequential than ever as we enter the final months before implementation of Obamacare in January 2014. Adding staff, adding locations or even altering income distribution systems are easy decisions in comparison, especially since they lend themselves to well-defined quantitative analysis. Creating and selecting options that involve the very nature and identity of groups is much more challenging. Three of the articles in this issue of the Communiqué explore different aspects of the answer to the question, “How do we secure our future?” The broadest view and the most basic recommendations are to be found in Will Latham’s article Strengthening Your Anesthesiology Group. Mr. Latham proposes two steps groups can take to reduce the pervasive environmental uncertainty: strengthen group governance and, with a more predictable decision-making process in place, develop a group-endorsed strategic plan. From defining the group’s...

Health insurance exchanges (HIEs) will open in every state by October 1, 2013, as mandated by the Affordable Care Act (ACA).  Their basic role will be to permit consumers to compare and purchase qualified insurance plans online.  Estimates of the numbers of individuals who will enroll in HIE plans during the six-month enrollment period that starts on October 1st vary from seven million (Congressional Budget Office) to four million (Citigroup investor survey released last Monday).  Many of these enrollees will be eligible for federal subsidies to help pay for the coverage. The issue for anesthesiologists and other physicians is whether to participate in the HIE health plans that are seeking to sign them up.  The clock is running; coverage under the HIE plans will begin as early as January 1, 2014.  This Alert will discuss the questions and considerations that will help groups decide how to proceed. Bear in mind that some...

The anesthesia community is rich in practice management educational resources.Since 1995, the American Society of Anesthesiologists has presented an annual conference on practice management in late January.  The conference is now a three-day meeting with multiple tracks, including an all-day program for residents.  According to the ASA, “This comprehensive educational event provides up-to-date information about the state of practice management including business and technology trends, changes in regulations and laws, and best practices to manage an anesthesiology practice in today’s environment.”  Next year’s meeting will be held in Dallas on January 24-26, and is beneficial for anesthesiologists, practice administrators, allied health professionals, consultants and others.  For further information, go to www.ASAhq.org.The Anesthesia Administration Assembly of the Medical Group Management Association hosts an annual national practice management meeting in the spring.  Several hundred administrators and a growing number of anesthesiologists attend this three-day event.  Like the ASA Practice Management Conference, the AAA meeting offers...

“Most people choose unhappiness over uncertainty.” — Timothy Ferris Anesthesiology groups are facing unprecedented challenges. How will the Affordable Care Act affect them? What will happen when ACOs get up and running? Should our group sell to an investment group? Should we pursue hospital employment? These are truly uncertain times. Unfortunately many groups are in a reactive mode, struggling with how to deal with threats and opportunities in the marketplace. This is often because their governance and management processes were formed at a time when there were fewer stressors and challenges. Some group are sprinting towards relationships that appear to offer financial reward and some level of security, but at the same time have the potential to severely limit the group’s and the physician’s autonomy. While there are situations where employment may be appropriate, many groups that pursue this course are “choosing unhappiness over uncertainty.” If your group intends to remain...

If you are an anesthesiologist practicing in a group of 100 or more eligible professionals (EPs) and submitting claims to Medicare under a single taxpayer number, you may be subject to the Value Based Payment Modifier (VBPM) in 2015.  By 2017, all physicians participating in Fee-for-Service Medicare will be affected by the VBPM.  This Alert is intended to help anesthesiologists familiarize themselves with the VBPM. The VBPM program, as provided for in the Affordable Care Act, is designed to connect the cost and quality of medical services in order to pay for “value” rather than the quantity of care.  It combines quality measures under the Physician Quality Reporting System (PQRS) with cost measures and a payment adjustment. The VBPM and PQRS are related but independent.  Readers are reminded that EPs who do not participate in PQRS in 2013 are subject to a -1.5% payment adjustment in 2015.  Non-participation in 2014 and...