Anesthesia in an Era of Scrutiny: Learn, Plan and Prepare to Appeal

That healthcare has been—and remains—in an extended period of heightened scrutiny is not news to anyone in the sector as a whole or anesthesia in particular. While Health and Human Services Secretary Tom Price, MD, has attempted to lighten physicians’ regulatory burdens by making participation in some bundled payment programs voluntary rather than mandatory, proposing to raise the exclusion threshold for MACRA’s Merit-Based Incentive Payment System to $90,000 in annual Medicare billings, and other actions, another form of scrutiny— government audits of providers’ use of federal healthcare dollars—has not waned. As this issue of Communiqué is about to be published, even Dr. Price himself is the focus of an Office of Inspector General (OIG) review to determine whether his use of private charter planes complies with federal travel requirements.¹

Anesthesia care providers and pain specialists are the focus of auditors’ attention in several areas. OIG has declared ferreting out fraud and abuse in opioid prescribing practices as a leading priority. Although the majority of painkillers are prescribed by primary care physicians, pain specialists are sure to be on the agency’s radar.

Similarly, this past June, the Centers for Medicare and Medicaid Services (CMS) directed data mining company eGlobal Tech to issue a comparative billing report (CBR) related to anesthesia services for lower endoscopic procedures. CBRs are educational tools that show an individual practitioner how their billing pattern on a given procedure compares with that of their peers at the state and national levels. But the reports are not merely educational. CMS uses CBRs as a strategy to ensure compliance and coding accuracy, and they could potentially make a group eligible for a CMS audit.

As Vicki Myckowiak, Esq., notes in her lead article for this issue, the government’s efforts to identify fraud and abuse are at an all-time high. OIG’s 2017 Work Plan includes two areas specific to anesthesia. In addition to providing an overview of this and other major types of audits of which anesthesia practices could find themselves a focus, she offers advice on how to minimize the impact of an audit, should it occur, and how to appeal should the outcome be unfavorable.

Also in this issue:

• Will Latham, MBA, of Latham Consulting Group explores the nuances of being an anesthesia leader—not an easy thing to do, considering that many physicians are, by nature, leaders themselves. How do you win the support—the “consent”—of a high-talent herd whose members do not view themselves as followers?
• Mark F. Weiss, JD, presents the metaphorical tale of the flea that killed the medical center CEO, the flea being a small but outspoken group whose relative power brought one senior executive’s reign quickly to an end. For anesthesia groups, “change within the organization, as well as change within a domain in which the organization interacts, can occur as a result of agitation by a vocal minority,” Mr. Weiss cautions. “Forget silo-like thinking and the world-view that results are directly proportional to efforts. Leverage, properly and forcefully applied at the right points, can move your world.”
• Robert Johnson, MBA, and Robert Stiefel, MD, of Enhance Healthcare Consulting, Inc., return with their second article on responding to a request for proposal (RFP). Once a formality that rarely led to an actual change in anesthesia providers, the RFP now demands an anesthesia group’s serious and concentrated attention. The ideal situation is to maintain a strong enough relationship with your facility to prevent an RFP from being issued, but if it happens—and that likelihood is increasing—there are steps to take and practices to follow that can maximize your group’s chances of preserving the relationship.
• Jody Locke, MA, ABC’s vice president of anesthesia and pain practice management, notes that while many anesthesia practices now include outpatient venues such as ambulatory surgery centers and endoscopy centers in the mix of environments in which they deliver services, not all outpatient settings are necessarily advantageous. Taking a closer look is in an anesthesia group’s best interest. Mr. Locke presents data and a case example.

We look forward to seeing many of you at ANESTHESIOLOGY^® 2017 in Boston, October 21-25 at Booth #1735.

With best wishes,

Tony Mira
President and CEO

¹Stevens, Matt. “Tom Price Says He’ll Stop Use of Private Jets Until After Review,” New York Times, September 23, 2017.