Defining General Anesthesia: A Moving Target?

Summary

For the last several years, anesthesia providers have been able to rely on a clear standard for determining whether or not an anesthesia service should be considered a general anesthetic. That standard may be going away. 

It’s something that philologists and etymologists would readily affirm: words and their meaning tend to be a moving target. That is, language and individual words within that language evolve over time so that the original meaning may no longer be reflected in later usage. “Cool” no longer refers only to relative temperature; it has also come to mean “neat.” And “neat” no longer just means “tidy”; it can also mean “awesome.” Interestingly, “awful” used to mean full of awe and wonder; now it has a completely negative connotation. So, yes, definitions are constantly changing, and medical terms are no exception to this dynamic.

Anesthesia’s Merriam-Webster

Over the years, compliance departments and medical practices have relied, in part, on definitions and position statements issued by the American Society of Anesthesiologists (ASA) to provide some semblance of authoritative guidance in compliance-related matters. Where Medicare, the Code of Federal Regulations and other authoritative sources are silent, the ASA is looked to for leadership on anesthesia-related matters. Indeed, the federal courts have taken into consideration the position statements of the ASA when formulating their opinions and handing down their decisions. How the ASA defines certain terms, therefore, is of some import.

As we have noted in previous alerts, the “definition” of a general anesthetic, according to the ASA, has for the last several years included the following verbiage: “If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.” The implication of the above statement is that if the patient loses consciousness—even for a moment, even if loss of consciousness was not part of the anesthesia plan—the anesthesia service is a general anesthetic.

It is the above language that led consultants and compliance experts around the country to advise their anesthesia clients that a planned monitored anesthesia care (MAC) service may not always end up as a MAC. As we have pointed out in the past, sedation is often used with modern MAC services, and that sedation is often in the form of propofol. When propofol is used, this often results in the patient losing consciousness at some point during the case. The planned MAC service has now, in such a scenario, just met the definitional threshold of a general anesthetic and should be so denoted on the anesthesia record.

Now all this may be changing. Or is it?

The Morphing of Meaning

On November 21, the ASA published on its website a revised version of its “Statement on Distinguishing Monitored Anesthesia Care (“MAC”) from Moderate Sedation/Analgesia,” which has an official approval date of Oct 18, 2023. Oddly enough, it was the MAC position statement that had contained the ASA’s definition of a general as reflected in the above-referenced section noted in bold. According to the new revised version of the statement, that entire section has been scrapped. In other words, the “If the patient loses consciousness . . .” language has now been deleted from the ASA’s MAC position statement.

Seeing a change in language, meaning or definition in this regard should come as no surprise. The anesthesia community remembers when, prior to the “if the patient loses consciousness” language, the ASA’s positional statement on MAC included the following statement: “Monitored anesthesia care refers to those clinical situations in which the patient remains able to protect the airway for the majority of the procedure.” The implication was that, if the patient could not protect the airway for a majority of the procedure, the mode of anesthesia was a general.

So, definitions do change; and the ASA’s definition or description of what constitutes a particular anesthesia technique is subject to periodic review and revision. We have just come through such a process, but what does this mean for the anesthesia provider who is charged with not only implementing an anesthetic but accurately documenting it?

Implication of Change

Excising the “if the patient loses consciousness . . .” verbiage was not the only change in the ASA’s October 18 MAC position statement. The following new language was added: “Please also refer to ASA’s Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia.” So, what do these changes mean from a practical, real-world standpoint for the anesthesia provider who must determine which anesthesia technique to mark on the intraoperative anesthesia record? It means that providers would be forced to consult the ASA’s above-referenced “Continuum of Depth of Sedation” position statement to determine whether their anesthetic service met the standard of a general or MAC. Here’s what that statement says—first, as to MAC:

Monitored Anesthesia Care (“MAC”) does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure.” Indications for monitored anesthesia care include “the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic.”

The statement continues with its description of a general anesthetic:

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

So, with MAC, the service does not require sedation. It’s not about sedation; it’s about monitoring, with the expectation that the patient may require conversion to a general or regional based on what’s taking place during the surgical session. Since today’s MACs often involve sedation drugs, the patients will at times lose consciousness. So, if that happens, would not this still meet the definitional threshold of a general—even with the dropping of the recent language from the MAC position statement?

With the new version of the MAC position statement now implemented, the default threshold for meeting a general, as described in the Continuum of Depth of Sedation statement, still describes a state of losing consciousness. That statement then goes on to use terms such as “often” and “may” to describe other circumstances that could arise in this unconscious state. That does not mean that a general must include an impairment of an ability to maintain ventilatory function or assistance in maintaining airway. So, the takeaway is that the removal of the recent general anesthetic definition (“if the patient loses consciousness and the ability to respond purposefully . . .”) may be of little consequence. The only unqualified requirement in the Continuum statement to meet the standard of a general is loss of consciousness (to include not being arousable).

So, here’s a scenario. It’s a planned MAC. You administer propofol. The patient loses consciousness and is not arousable, though the patient remains non-intubated. With the new version of the MAC position statement, this scenario would still reflect a general, and “general” should therefore be documented as your anesthesia technique.

Definitions and descriptions may morph from time to time; but, occasionally, the meaning remains essentially the same. If you have any questions on this topic, feel free to contact your account executive.

With best wishes,

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/defining-general-anesthesia-a-moving-target/

2024 OPPS Final Rule: Quality Programs

Sometimes we buy on time. That may call for making a few installment payments. Our reporting on the highlights of the 2024 Outpatient Prospective Payment System (OPPS) final rule seems to be working out in similar fashion, i.e., in installments. In this third installment on Medicare’s final rule for the outpatient hospital setting, our focus will be exclusively on the quality programs set forth by the Centers for Medicare and Medicaid Services (CMS), effective January 1, 2024.

According to a fact sheet released by CMS, the agency is finalizing changes to the Hospital Outpatient Quality Reporting (OQR) and Rural Emergency Hospital Quality Reporting (REHQR) programs to further its goals of “meaningful measurement and reporting of quality of care in the outpatient setting.”

Outpatient Quality Reporting

The Hospital OQR program is a pay-for-reporting measure that requires hospitals to meet quality reporting requirements. Facilities that fail to meet these requirements will receive a reduction of 2.0 percentage points in their annual payment or fee schedule update.

In the 2024 OPPS final rule, CMS is finalizing modifications of three measures:

• The COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) measure to align with the updated Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network measure specifications;
• The Cataracts: Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery measure, to require use of one of three specific survey instruments to measure change in visual function pre- and post-operatively to further standardize data collection and reduce facility burden; and
• The Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients measure, to align with updated clinical guidelines.

In addition, CMS is finalizing, with modification, the adoption of a new measure in these programs: the Risk-Standardized Patient-Reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty measure. According to the CMS fact sheet, this measure “will provide specific insight into the quality of care of a common procedure.” The measure will extend the voluntary reporting period to a total of three years prior to requiring mandatory reporting beginning with the 2028 reporting period for the 2031 payment determination.

Conversely, CMS is not finalizing its proposal to re-adopt the Hospital Outpatient Facility Volume Data on Selected Outpatient Surgical Procedures measure after consideration of commenter feedback. Commenters requested that CMS reconsider what data is collected for this measure to provide a complete picture of procedural volume that is meaningful to both patients and providers. The agency is also reassessing how the volume data is publicly displayed to ensure meaningfulness and relevance to providers, consumers, and other interested parties.

Further, the final rule adopts an additional measure in the Hospital OQR Program: the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults electronic clinical quality measure (eCQM). The purpose of this measure is to promote patient safety. The measure extends the voluntary reporting period to a total of two years prior to requiring mandatory reporting beginning with the 2027 reporting period for the 2029 payment determination.

CMS is not finalizing its proposal to remove the Left Without Being Seen measure due to a recent increase (worsening) of LWBS rates in the agency’s routine monitoring and evaluation that warrants further investigation. Requests for comments were also solicited in the measure topic areas of patient safety and sepsis, behavioral health (including mental health and suicide risk), as well as telehealth in the hospital outpatient setting. A summary of the comments received is included in the final rule.

Rural Emergency Hospital Quality Reporting

The REHQR Program is a new quality reporting system for specially designated rural emergency hospitals (REHs) that must provide emergency department (ED) services and observation care and may also opt to provide additional outpatient services. These REHs are required by statute to submit quality measure data.

In the 2024 OPPS final rule, CMS is finalizing the adoption and codification of several standard quality program reporting policies, as well as the adoption of four initial measures for the REHQR Program. The four initial measures, consisting of three claims-based measures and one chart-abstracted measure, are:

• Abdomen Computed Tomography – Use of Contrast Material;
• Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients;
• Facility Seven Day Risk Standardized Hospital Visit Rate after Outpatient Colonoscopy; and
• Risk-Standardized Hospital Visits Within Seven Days After Hospital Outpatient Surgery.

In addition, CMS summarized comments received on the use of eCQMs, care coordination measures, and a tiered approach for quality measures and reporting requirements to incentivize REH reporting.

For a comprehensive review of the quality reporting rules for 2024, please consult the final rule, which can be found at the following website: 2023-24293.pdf (federalregister.gov)

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/2024-opps-final-rule-quality-programs/

What Makes for an Ideal Relationship Between an Anesthesia Practice and the Hospital Administration?

Summary

Not every anesthesia practice has a winning strategy when it comes to the all-important relationship with the hospital. Today’s article addresses the dynamics of that relationship and how anesthesia groups can successfully manage it.

Too many anesthesia practices are experiencing a less than collaborative relationship with the administration of the facility where they provide services. Given what an important role anesthesia plays in the management of the operating rooms, this can be a particularly troubling state of affairs. Anesthesia services bring such value to the facility.  The anesthesia provider does more to enhance the patient’s overall surgical experience than the surgeon, leading many to wonder why the relationship is not more compatible. Obviously, part of the explanation is historical. In many facilities the anesthesia providers were the masked men about whom little was known. More recently, many in the administration see them as the annoying providers who are always asking for a bigger subsidy or other forms of financial support.

Clearly, it does not help when the only interactions between the anesthesia department and the hospital administration occur at the time of a contract renewal. Some might even argue that the lack of a productive and meaningful dialogue is by design: it is part of a strategy to enhance the administration’s power over the group. An arm’s length relationship makes it easier to hold the anesthesia providers accountable. While such relationships may have been the norm in the past, most observers would now agree this status quo is no longer appropriate in today’s highly competitive healthcare environment. The anesthesia challenge is how to change the paradigm.

Administration Perspective

Certainly, we all need to be understanding of the challenges faced by hospital administrators in the current environment. If the anesthesia practice is experiencing revenue challenges, we can be sure that the hospital is experiencing them as well. If the anesthesia practice wants to discuss additional financial support, it is safe to assume that it is not the only specialty engaged in such efforts. It should not come as any surprise that administrative staff is being challenged on many levels. This makes it especially difficult to get their attention and establish a working dialogue.

Anesthesia’s Strategy

Best practices are notable in medicine. Some anesthesia practices pride themselves on their close working relationship with administration. Key members have regular meetings with hospital leadership and are in the loop in critical decision-making affecting the management of the operating rooms. Some even have members on the hospital board of directors. The question is, to what do we attribute such administrative success? What strategies have these practices pursued to ensure they have an optimal working relationship with their customers?

As is true of so many things, success is a function of focus and commitment. The group must be committed to a close working relationship with administration. It does no good to simply view the CEO as a tough customer. He must be seen as a business partner. Collaborative problem-solving must be the goal. Regular and consistent communication is essential. This seems so logical and such common sense; why is it not the norm? For one thing, everyone’s time is valuable and scarce. Anesthesia concerns are not often at the top of the list of hospital executives who are typically more focused on developing new lines of business and revenue opportunities. There is often a perception that administration is most happy when they don’t have to deal with any anesthesia issues. Most anesthesia providers are happiest when they have the freedom and flexibility to do their cases as they see fit. Regulatory requirements and administrative responsibilities are nothing more than an unnecessary annoyance to most.

Clearly, the anesthesia provider’s perspective is conditioned by the nature of anesthesia practice where the objective is to get patients comfortably and safely through the trauma of surgery. Anesthesia tends to have the shortest decision cycle in medicine. Critical clinical issues rarely require more than a matter of seconds to resolve. When they need something from administration, like a bigger subsidy, they approach it with the same level of impatience they approach clinical care. Unfortunately, this is not how business people think or act. More often than not, the implicit objective of management decision-making is maintenance of the status quo. Herein lies a fundamental disconnect. Administrators want and need data to analyze and assess options. This is what anesthesia providers often perceive as paralysis by analysis. What many groups have come to understand is that this is an opportunity for education. They need to have the patience and commitment to educate the administration.

One anesthesia chairman developed an operating room utilization report that compared coverage hours by billable anesthesia hours by anesthetizing location. Each month he dropped off a copy of the report for the COO. At first the COO did not take the information seriously, but over time he came to see its value. Eventually, the chairman was able to convince the hospital not to open any location that would not generate 45 ASA units. The process took a number of months, but eventually the administration understood its relevance.

A good strategy that has worked for many practices is to be seen as a problem solver. Identify challenges and issues that need to be addressed and provide workable solutions. With each problem or issue that the practice addresses and solves, the group buys credibility. Eventually, it becomes a go-to source for solutions.

Ultimately, a practice must be seen as a good business partner. Strong leadership is critical. It is essential that the practice speaks with one voice and that all providers act accordingly. Disunity can easily be the fatal flaw that causes administration to lose faith in the practice and consider other options. If you have questions, feel free to contact your account executive.

With best wishes,

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/what-makes-for-an-ideal-relationship-between-an-anesthesia-practice-and-the-hospital-administration/

2024 OPPS Final Rule: Additional Details

In a follow-up to our previous alert, we would like to provide our readers with additional takeaways from the 2024 Outpatient Prospective Payment System (OPPS) final rule, that was published earlier this month by the Centers for Medicare and Medicaid Services (CMS). Based on a fact sheet provided by CMS that summarizes the key provisions of the final rule, hospitals officers will want to be aware of the issues highlighted below.

Dental Services

For 2024, CMS is finalizing Medicare payment rates for over 240 dental codes to align with the dental payment provisions in the 2023 Physician Fee Schedule final rule by assigning them to clinical APCs. This is intended to bring greater consistency in Medicare payment for different sites of service and help ensure patient access to dental services performed in the hospital outpatient setting.

CMS is reassigning HCPCS code G0330 from the Dental Procedures APC (APC 5871) to Level 4 ENT Procedures (APC 5164) for 2024. HCPCS code G0330 is used to describe facility services for dental rehabilitation procedures performed on a patient who requires anesthesia (e.g., general, monitored anesthesia care) and use of an operating room. The final APC assignments and status indicators for the dental codes can be found in the CY 2024 OPPS Addendum B.

Rural Emergency Hospitals

As you will recall, the 2023 OPPS final rule established the Rural Emergency Hospital (REH) provider type. A hospital is eligible to convert to an REH if it is a critical access hospital or rural hospital with no more than 50 beds, participating in Medicare as of the date of enactment of the Consolidated Appropriations Act (CAA), 2021. Eligible hospitals that convert to an REH receive an enhanced rate for REH services and a fixed monthly facility payment.

While some Tribal and IHS hospitals have expressed interest in converting to an REH, they have expressed significant reservations about transitioning from their existing payment methodology under the All-Inclusive-Rate (AIR), published annually by the IHS in the Federal Register, to the REH payment methodology. In response, the 2024 OPPS final rule implements a policy where IHS and Tribal facilities that convert to REHs will be paid for hospital outpatient services under the same AIR that would otherwise apply if these services were performed by an IHS or Tribal hospital that is not an REH. The existing beneficiary coinsurance policies applicable to such services under the AIR would remain the same. Per the rule, IHS and Tribal facilities that convert to REHs would receive the REH monthly facility payment consistent with how this payment is applied to REHs that are not tribally or IHS operated.

340B Drug Program

Section 340B of the Public Health Service Act allows participating hospitals to purchase certain covered outpatient drugs from manufacturers at discounted prices. For 2024, CMS will continue to pay for 340B acquired drugs and biologicals at the statutory default rate, which is generally ASP plus six percent. The payment for 340B-acquired drugs and biologicals will not differ from the payment rate for drugs and biologicals not acquired through the 340B program.

CMS issued a final rule prior to the release of this 2024 OPPS final rule on November 2, 2023, discussing the remedy for payment for 340B acquired drugs for CYs 2018 to 2022. We will be providing information on this topic in an upcoming alert.

Industry Response

The American Hospital Association was quick to weigh in on its overall assessment of the 2024 OPPS final rule. In a press release earlier this month, the organization’s executive vice president, Stacey Hughes, expressed concern that the government had once again provided an inadequate update to hospital payments for Medicare services. The 3.1 percent increase for next year was seen as insufficient given the financial difficulties still facing many of America’s frontline medical facilities. She expressed hope that the U.S. Congress would step in to provide additional funding before the end of the year.

On a separate issue, the AHA’s executive vice president expressed a desire to cooperate with CMS in its effort to increase price transparency, stating:

The AHA will be carefully reviewing the changes to the Hospital Price Transparency Rule to ensure they continue to advance our shared objective with CMS of making it easier for patients to access pricing and cost information while reducing unnecessary administrative burden and costs on hospitals and health systems.

We will be providing an additional alert in the coming weeks addressing the quality incentive programs for outpatient hospital services, as well as a treatment of the separate 340B drug final rule also released this month.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/2024-opps-final-rule-additional-details/

2024 Medicare Physician Fee Schedule: Impact on Anesthesia

Summary

Every November, the federal government issues its physician fee schedule for the following year. The rule for 2024 contains provisions that will impact all specialties. Today’s alert looks at the possible impact the 2024 final rule will have on anesthesia providers, in particular. 

The Centers for Medicare and Medicaid Services (CMS) has released its 2024 Medicare Physician Fee Schedule (PFS) final rule. While there are minimal provisions that apply directly to the anesthesia specialty, anesthesiologists and CRNAs will find a few noteworthy changes for next year—not the least of which involves the rate of reimbursement for Medicare services. In addition to the 2,709-page rule, CMS also published a fact sheet that attempts to summarize the major changes for next year. The following will act to provide a couple of those highlights that will be of interest to the anesthesia community.

Reimbursement Rates

The finalized 2024 PFS conversion factor is to be set at 32.74. This represents a decrease of 1.15 from the current (2023) PFS conversion factor of 33.89, translating to a reduction of 3.4 percent. For anesthesia providers, this conversion factor will come into play when submitting claims for non-anesthesia services, i.e., services other than “TOS 7,” such as invasive lines, postoperative pain procedures and ultrasound guidance.

While the overall conversion factor has been lowered, the final rule indicates that there will be an increase in payments for certain evaluation and management (E/M) services. We submit an E/M code on behalf of our anesthesia clients whenever they perform a pain round (other than those involving an indwelling epidural catheter) or an anesthesia consult, for example.

The anesthesia conversion factor for 2024 has been set at 20.4349. This reflects a 0.69 drop from the current (2023) anesthesia conversion factor of 21.1249, or a 3.27 percent reduction. As we indicated in our recently published “Special Alert,” the final anesthesia conversion factor for 2024 ended up being even less—if ever so slightly—than the proposed anesthesia conversion factor. The 2024 PFS proposed rule set the anesthesia conversion factor at 20.4370. So, the final number comes in just a tad lower than what was originally suggested. To some, this would be seen as adding insult to injury.

The final rule includes comparative data showing the estimated overall change to Medicare reimbursement, per specialty, expected for next year. In Table 118 (pp. 1950-1951) of the 2024 fee schedule, we are treated to a chart with 50 specialties—give or take—depicting the expected change in their overall reimbursement for 2024, as compared with current-year levels. Interestingly, and despite the overall lower conversion factor, some specialties actually had a projected positive change in their Medicare payment percentage. For example, both endocrinology and family practice are shown to have an overall three-percent increase in expected reimbursement. Conversely, specialties such as anesthesiology, pathology and audiology are slated to realize a reduction of two percent. Interventional radiology was impacted the most with a projected loss of four percent in their Medicare reimbursement for next year.

The key takeaway is that the government is continuing to put downward pressure on provider reimbursement relative to Medicare services—in spite of the fact that overall costs in the U.S., from food to housing, are dramatically rising. Once again, it will be up to Congress to step in with a last-minute bill that provides some measure of correction to this trend—assuming they are so inclined.

Provider Enrollment

The 2024 final rule contains several regulatory changes to the Medicare and Medicaid provider enrollment process, which of course would extend to the anesthesia provider community. These changes include, but are not limited to, the following:

• Creation of a new Medicare provider enrollment action labeled a “stay of enrollment,” which CMS believes will ease the burden on providers while strengthening Medicare program integrity.
• Requiring all Medicare provider and supplier types to report additions, deletions, or changes in their practice locations within 30 days.
• Establishing several new and revised Medicare denial and revocation authorities.
• Clarifying the length of time for which a Medicaid provider will remain in the Medicaid termination database.  

Specialty Response

It didn’t take long for the anesthesia community, through one of its primary lobbying organizations, to weigh in on the provisions of the final rule. The American Society of Anesthesiologists (ASA) released a statement on the same day the final rule was published, calling on the U.S. Congress to block what it termed the “payment cut” that will be realized by anesthesiologists and other Medicare providers should the 2024 conversion factors go into effect.

The ASA statement states, in part:

Congress must act before the end of the year to prevent these deleterious cuts from negatively impacting the Medicare patient population’s access to care. A critical, immediate fix that Congress can do is to block the new G2211 payment code that CMS will launch in its 2024 PFS, which creates instability and imbalance in the payment system. This can be done efficiently by Congress with no impact to the Medicare budget. Congress could also pass hold harmless legislation to protect other important Medicare services from the G2211 generated cuts.

The ASA noted that nearly 90 percent of the negative adjustment to the conversion factors is attributable to a new bonus payment for office and outpatient E/M services—reflected by code G2211 that CMS has finalized for use in the 2024 payment year. So, the ASA is asserting that the implementation of G2211 “will significantly reduce anesthesiologist payments in 2024.”

The ASA places hope in a bill currently circulating in the U.S. House of Representatives. H.R. 2474—the Strengthening Medicare for Patients and Providers Act—seeks to implement a long-term fix to what it deems a broken reimbursement system.

We will have more details from the final rule in upcoming alerts, including new provisions dealing with E/M, telehealth and incentive programs. For a full treatment of the final rule, click on the following link: Federal Register :: Public Inspection: Medicare and Medicaid Programs: Calendar Year 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; etc.

If you have any questions on this topic, please contact your account executive. 

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/2024-medicare-physician-fee-schedule-impact-on-anesthesia/

2024 OPPS Final Rule: What Hospitals Need to Know

It’s that time of year again. The Centers for Medicare and Medicaid Services (CMS) has been busy, putting out several new rules in just the last few days, including the 2024 Outpatient Prospective Payment System (OPPS) final rule. In addition to the voluminous OPPS rule, CMS also published a fact sheet that summarizes the major provisions of the rule. The following will highlight some of the more key provisions found in the fact sheet.

Payment Rates

The 2024 OPPS final rule increases the OPPS payment rates by 3.1 percent for hospitals that meet applicable quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3.3 percent, reduced by a 0.2 percentage point for the productivity adjustment.

Intensive Outpatient Program

An intensive outpatient program (IOP) “is a distinct and organized outpatient program of psychiatric services provided for individuals who have an acute mental illness or substance use disorder, consisting of a specified group of behavioral health services paid on a per diem basis under the OPPS or other applicable payment system when furnished in hospital outpatient departments, CMHCs, FQHCs, and RHCs.” The rule adds service codes to recognize activities related to care coordination and discharge planning, as well as to recognize the role of caregivers and peer support specialists in PHPs and IOPs.

Physician Certification and Plan of Treatment Requirements for IOP

The Social Security Act (the Act), as amended, requires that a physician determine that each patient needs a minimum of nine hours of IOP services per week. This determination must occur no less frequently than every other month. CMS is codifying this requirement in regulation for IOP provided in all settings.

IOP Payment Rates

CMS is establishing two IOP Ambulatory Payment Classifications (APCs) for each provider type:

• One for days with three services per day; and
• One for days with four or more services per day.

While no Medicare IOP benefit currently exists, CMS will use the OPPS data set to capture data from hospital claims that are not identified as IOP but that include the service codes and intensity required for an IOP day.

RHCs and FQHCs

The rule sets payment for three IOP services/day; payment is based on the hospital rate. That is, RHCs will be paid the 3-services per day payment amount for hospital outpatient departments. For FQHCs, payment will be the lesser of a FQHC’s actual charges or the 3-services per day payment amount for hospital outpatient departments. For grandfathered Tribal FQHCs, payment will be the Medicare outpatient per visit rate as established by the IHS when furnishing IOP services, and payment is based on the lesser of a grandfathered Tribal FQHC’s actual charges or the Medicare outpatient per visit rate.

Opioid Treatment Program (OTP) Settings

The rule finalizes CMS’ proposal to extend IOP coverage to OTPs. CMS is establishing a weekly payment adjustment via an add-on code for IOP services furnished by OTPs for the treatment of opioid use disorder (OUD) and revising the regulatory definition of opioid use disorder treatment services to include IOP services. The payment adjustment will also be updated annually based on the Medicare Economic Index and adjusted by the Geographic Adjustment Factor.

Medicare will pay for IOP services provided by OTPs as long as each service is medically reasonable and necessary and not duplicative of any service paid for under any bundled payments billed for an episode of care in a given week. For an OTP to receive the additional payment adjustment for IOP services, a physician or non-physician practitioner must certify that the beneficiary requires a higher level of care intensity compared to existing OTP services, and the certification, plan of care, and all other applicable requirements are met. In addition, CMS is not finalizing its proposal to deduct the payment rates for individual and group therapy services that are included in the existing OTP bundled payment.

Partial Hospitalization Program

Partial Hospitalization Program (PHP) Rate Setting

The final rule includes updates to Medicare payment rates for partial hospitalization program services furnished in hospital outpatient departments and CMHCs. The PHP is an intensive, structured outpatient program provided as an alternative to psychiatric hospitalization, consisting of a specified group of mental health services paid on a per diem basis for a minimum of 20 hours of PHP services per week under the OPPS, based on PHP per diem costs.

Update to PHP Per Diem Rates

CMS is expanding the existing rate structure to include two PHP APCs for each provider type; one for days with three services per day and one for days with four or more services per day. As a result, CMS is increasing payment rates for higher-intensity days in all settings.

For 2024, CMS is calculating hospital-based and CMHC PHP payment rates for three services per day and four or more services per day based on cost per day using OPPS data that includes PHP and non-PHP days, which is a change from the current methodology of using only PHP data.

Clarification about Substance Use Disorder (SUD) Treatment under PHP

The 2024 final OPPS rule clarifies that Medicare covers PHP for the treatment of substance use disorders (SUD). Specifically, notwithstanding the requirement that PHP services are provided in lieu of inpatient hospitalization, Medicare covers PHP for the treatment of SUD, and CMS considers services that are for the treatment of SUD and behavioral health generally to be consistent with the statutory and regulatory definitions of PHP services.

————-

We will have more details arising from the 2024 OPPS final rule in upcoming alerts.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/2024-opps-final-rule-what-hospitals-need-to-know/

Why Anesthesia Practices Should Have an Appropriate Collection Agency

Summary

There is a difference between what a billing service can do and what a collection agency can do. There are also differences in agencies. Despite these differences, an anesthesia group must align itself with a collection agency, but it must manage its expectations. 

Many anesthesia providers often ask this question: if we have contracted with a full-service billing company, why do we need a collection agency? The answer is not always obvious but can be significant.

Comparing Efficiencies

Completely resolving all account balances requires the careful navigation of a challenging matrix of options. The scope of services offered by a billing company is always designed to maximize collections in the most compliant and cost-effective manner possible. In selecting a billing service, most practices focus on fee, which is typically defined as a percentage of net collections. Billing companies provide an efficient service that relies heavily on a balance between people and computer technology.

Collection agency fees are determined based on a completely different set of assumptions. While billing services have prescribed protocols based on the practice’s payer mix, collection agencies start by asking the question: why is the balance still unpaid? Their approach is considerably more labor intensive and is sometimes described as dialing for dollars. Agents go to great lengths to ferret out demographic details and to negotiate with patients directly. Because this model is considerably more expensive, collection agency fees are dramatically higher. It is not uncommon for a collection agency to charge 20 to 40 percent of what they actually collect.

No matter how effective the billing service, it is always useful to contract with a reputable collection agency as a fall back for exceptional accounts that do not respond to traditional collection strategies. Especially given the challenges of today’s market for medical services, it is always good to have qualified collectors review unpaid accounts, especially given that they may have different tools available to them. It should be clearly understood that whatever collections are generated by the agency will never be more than a small percentage of overall collections. In that sense, what the collection agency generates is sort of found money that would otherwise have been lost. It is the rare anesthesia practice that refers more than five percent of monthly accounts to an agency and rare that the agency collects more than 25 percent of what is referred.

The Agency Toolkit

What can collection agencies do that most billing companies do not do? Sometimes the most significant impact of a collection agency is the initial letter sent to the patient informing them that their account has been referred for collections. For patients who have been in denial about their responsibility for their anesthesia bill, the initial collection agency letter can be a wake-up call. Many patients hate the notion of having a medical bill be referred to a credit agency. In addition, though, most collection agencies provide the following services not typically performed by a billing company:

• Skip tracing to identify demographic details not previously provided by the facility or not otherwise available to track down and contact the patient.
• Aggregating claims when the agency works with other providers or the facility in an effort to make a more compelling claim.
• Filing legal claims that will compel the patient to pay the balance due.
• Reporting to credit agencies so that their delinquency will affect their credit report for high balance accounts.

Collection agencies have developed unique strategies for some of the most challenging aspects of the collections process. There is no greater challenge than the pervasive use of cell phones with caller ID. Most people do not respond to calls from numbers they do not recognize. A major challenge today is patient understanding of insurance coverage. Too many patients assume that having insurance eliminates their responsibility for payment. Too often, patients look at their explanation of benefits and decide the provider has been paid enough. This is when and how the legal battle begins.

Which Agency is Right?

A review of Coronis clients reveals dozens of collection agencies across the country. All claim they can resolve the toughest accounts, but their results vary considerably. The bottom line is that, if billing has exhausted their efforts, the collection agency may not have great results. What you hope for is that they have managed to resolve accounts where either the information was either incomplete or the patient was particularly intransigent. The key to an effective relationship is complete transparency and effective reporting.

Some agencies are more aggressive than others. Many make bold promises of performance. A written agreement is always recommended; but, in addition, it is important to make sure that the approach and strategies used by the agency are consistent with the core values of the practice. An overly aggressive collection agency can cause unnecessary problems with administration. If you are concerned about the performance you are getting from your current agency, and you are interested in hearing about other solutions Coronis Health can offer, please contact your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/why-anesthesia-practices-should-have-an-appropriate-collection-agency/

Mum’s the Word: Are Hospitals Underreporting Problematic Providers?

It wasn’t an out-and-out lie, really. You just failed to mention a few details; that’s all! This may be representative of the internal dialog taking place within the heads of more than a few hospital managers these days as they attempt to rationalize a reporting “oversight” on their part. On the one hand, hospitals are required to provide detailed reports pertaining to their clinical practitioners—including the less flattering aspects; on the other hand, fully complying with the rules could negatively impact the hospital’s overall operation. At least, that seems to be the thinking.

The Requirement Revisited

One of the agencies falling under the aegis of the U.S. Department of Health and Human Services (HHS) is the National Practitioner Data Bank (NPDB). Hospitals are required to provide the NPDB with information concerning the clinicians who practice at their facility. The agency wants to know, among other things, if there are problematic providers who have slipped through the cracks of scrutiny and who may therefore prove potentially harmful from a patient care and safety standpoint.

In checking the NPDB website, here is what hospitals are expected to include in their reports to the federal data bank, pertaining to their medical staff:

• Medical malpractice payments
• Adverse clinical privileges actions
• Adverse professional society membership actions
• State licensure and certification actions
• Federal licensure and certification actions
• Negative actions or findings by a peer review organization
• Negative actions or findings by a private accreditation organization
• Exclusions from participation in a Federal or state health care program (including Medicare and Medicaid)
• Other adjudicated actions or decisions
• Health care-related civil judgments and criminal convictions in Federal or state court

So, obviously, the NPDB wants to keep abreast of potentially problematic providers operating within the confines of our nation’s hospitals. The agency’s website contains detailed instructions on how the required information is to be reported, amended, corrected, etc. The problem is that some hospitals are not complying to the extent expected and required.

A Report of Underreporting

The problem is that doctors move around. If they get into trouble in one state due to a civil judgment or license revocation, they simply move to another state, get a license in the new jurisdiction and set up shop. The medical facilities in the new state may be unaware of any previous problems facing the doctor who is now submitting a request for hospital privileges. The questions is, how hard is the hospital looking into this new provider’s past?

There are over 255,000 doctors in the NPDB going back to 1990. Of these, 17,008 lost their license, and a little over 8,700 faced disciplinary action. But do these figures accurately reflect the true numbers of adverse actions for the doctors in the database? According to the U.S. Health Resources and Services Administration, about 45 percent of hospitals have never submitted a single report involving adverse actions taken against a doctor’s privileges in the 33 years that the data bank has been in operation. How could this be?

According to an Oct 30 article in Gothamist, which investigated hospital underreporting:

One obvious reason for underreporting: If you are a hospital, employing a doctor, or if you are a colleague of a doctor who has done something shady, there are reputational disadvantages to reporting them. There’s really no enforcement mechanism for these reporting requirements . . . if a hospital fails to report a misbehaving doctor to the data bank, practically speaking, no one is going to catch that.

In addition, according to the NPDB website, hospitals are required to report long-term restrictions on a physician’s privileges, but only if they exceed 30 days. This may act as a loophole, letting hospitals off the hook, from a reporting perspective, if the 30-day threshold is not met. According to Becker’s Hospital Review, there are a couple other factors that allow hospitals to limit their reporting in this area or to suppress such reporting:

• Hospitals can often prevent malpractice lawsuits from being added to a physician’s record by removing their names from settlement agreements, even if the physician is a named defendant.
• Provider resignations have to be reported only if a hospital is officially investigating a physician when they resign or if a physician resigns to avoid an official investigation, which is difficult to prove. Voluntary resignations are not required to be reported. Hospitals are known to warn physicians to resign before an investigation is launched into their conduct to avoid being reported to the data bank.

While there may exist loopholes and little enforcement, hospitals would do well to fully report adverse actions associated with its privileged providers. It’s the law, and patient safety should always be paramount.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/mums-the-word-are-hospitals-underreporting-problematic-providers/