Presurgical Clinics: A Growing Strategy for Anesthesia Practices

Summary

Over the years, we have seen a group here or there showing interest in adding a presurgical testing clinic to their array of services. But an analysis of the risk-reward dynamic is essential before proceeding into such a venture. 

Last week, we brought you an alert on certain strategies being used by anesthesia groups across the country to enhance their revenue opportunities. We discussed acute pain, chronic pain, adding new places of service and experimenting with ketamine clinics. In keeping with this theme, there is another avenue of additional reimbursement potential that some practices are now pursuing: presurgical testing. What does this service entail, and what can anesthesia groups expect to reap by adding this component to their line of services?

Defining Our Terms

Over the years, we have noticed a growing interest within the anesthesia community in the concept of presurgical clinics. Often, this interest was sparked by a speaker at a state or national event or by a hired consultant who presented the idea to the group as a can’t miss revenue opportunity. Essentially, these clinics perform what is sometimes called pre-anesthesia testing (PAT) or presurgical clearances on patients who are scheduled for various surgeries—surgeries that will ultimately involve anesthesia services. For convenience, we will use the acronym PAT to identify this service.

In many cases, it is not the anesthesia providers performing the PATs. Rather, the group hires a nurse practitioner (NP) to see the patient, perform the testing (eg, vitals, blood work, etc.), and generally evaluate the patient to determine if he or she can be expected to successfully withstand the scheduled procedure. For example, if the upcoming surgery involves the cardiovascular system and the surgeon has reason to believe the patient may have difficulty with the surgery or the anesthesia, the surgeon may refer the patient to the PAT clinic to get a full workup and recommendation as to the suitability of the patient for the operative session.

Determining the Propriety

Seeking to add value to the group in the eyes of the surgeons and hospital administration is certainly commendable. And looking for ways to add another revenue stream in this financially challenging time is quite understandable. The PAT clinic concept would seem to check both of these boxes. There are, however, some factors that anesthesia groups should take into consideration before dipping their toe into these waters.

The first thing to consider is the propriety of this arrangement. How appropriate is it for an anesthesia group to submit a claim for evaluating a patient in connection with a scheduled case for which the same anesthesia group will be billing for anesthesia services? The anesthesia provider is already required to perform a pre-anesthesia assessment (PAA) prior to the anesthesia service. That PAA is bundled into the anesthesia code that appears on the claim form. In other words, the PAA is not separately billable. But now we have this additional evaluation, in the form of a PAT session, for which anesthesia providers are seeking separate payment.

Typically, claims for these services would be submitted with a relatively low-paying evaluation and management (E/M) code. And, of course, groups will have to provide human resources to staff the clinic and perform these pre-surgical clearances. The question is this: are the compliance risks and resource requirements worth the reward?

There are three typical ways in which an anesthesia provider obtains payment from the E/M code set: (a) a postoperative pain round, (b) the PAA where the case was canceled prior to induction, and (c) an anesthesia consult. In scenario “a,” the service is separate and apart from the anesthesia service. In scenario “b,” the PAA that is usually bundled becomes payable only because the anesthesia service never took place. In scenario “c,” the consult is only payable if it represents a service that is above and beyond the bundled PAA. The question is, does the PAT constitute an anesthesia consult; and, if so, does it meet above-and-beyond criterion?

To answer the above questions, we need to determine the following: (a) who is performing the PAT, and (b) what does this evaluation service actually entail? According to the Medicare State Operations Manual in its treatment of the conditions of participation (CoPs)—that is, the conditions that hospitals have to meet in order to participate with Medicare—we are given a list of provider types that are authorized to perform a PAA. That list does not include an NP. A nurse practitioner is not an anesthesia provider, so an NP cannot perform a pre-anesthesia assessment. It follows that an NP cannot also perform an anesthesia consult. If these PATs are essentially an anesthesia consult, then it is entirely inappropriate for such services to be performed by the NP.

If these PATs or presurgical clearance screenings are not an anesthesia consult, then what are they? Our understanding is that patients undergoing these screenings are being referred to the anesthesia group by the patients’ surgeons. Again, the purpose is purportedly to check out whether the patient is a legitimate candidate for surgery and/or anesthesia. But why isn’t the surgeon doing this? Isn’t this determination part of the surgeon’s own health and physical (H&P) exam prior to surgery? Why does there need to be an additional step in the process—additional to the surgeon’s H&P and the anesthesiologist’s PAA? Furthermore, if the PAT service is more analogous to an H&P than the PAA, why is the anesthesia group’s NP more competent to perform this service than the patient’s own surgeon? The point we’re trying to make here is that some payers may eventually question the medical necessity of this supplemental and relatively amorphous evaluative service (in addition to the bundled H&P and the bundled PAA).

Proceed with Caution

Despite the concerns addressed above, the case can be made that the service being provided in these PAT clinics may be deemed medically appropriate and thus payable in at least some instances. As with anesthesia consults, claims for these screenings should not be routine, i.e., not submitted for every patient or just any patient. In assessing both the risk and opportunity relative to presurgical testing services, one anesthesia compliance attorney has indicated the following:

1. Preoperative assessments can be billed, provided that very rigid controls and prerequisites are implemented and followed, and further provided that the anesthesia group has a tolerance for some risk.
2. As to the risk, S. v. Chen, a False Claims Act (FCA) case, may be somewhat instructive. The case was brought against Dr. Chen, an anesthesiologist, for submitting consultations (the highest consult code available) for each of his anesthesia cases. The jury found that he submitted over 3,500 claims inappropriately, and the court of appeals affirmed. So, if claims for PAT services are (a) deemed to be akin to an anesthesia consult claim, and (b) submitted routinely, it could result in an FCA action.
3. The Chair of the Committee on Economics for the American Society of Anesthesiologists (ASA) wrote an article in 2014, explaining the circumstances under which the ASA believes these PAT-type services can and cannot be billed, as follows:
   a. The service must be significantly above and beyond the usual pre-anesthesia eval, and as such would need to address items that are not addressed in the routine pre-anesthesia eval.
   b. The conditions examined could include a comprehensive exam of the patient’s entire medical condition, as well as management of those issues that need to be corrected or optimized prior to surgery.
   c. These visits would be billed “under rare conditions.”
4. Where the PAT or pre-surgical clearance clinic sees a large percentage of surgical candidates, such as all those with a physical status indicator of III or higher, the provider of the PAT services may pop up on the payer’s radar, and an audit may ensue. The provider and/or group would need to be able to accept that risk.

Of course, the above does not directly address the scenario where an NP employed by the anesthesia group is the one who is performing the bulk of these screenings. Since an NP cannot perform an anesthesia consult, any evaluative work performed by the NP may be deemed by the payer (or the government) as necessarily outside the scope of the PAA and thus not an attempt to unbundle the PAA. Nevertheless, it would be wise for anesthesia groups that are looking to employ NPs for this very purpose to recognize there is risk and that such services should not be routine.

If you have further questions about PAT clinics, please contact your account executive.

With best wishes,

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/presurgical-clinics-a-growing-strategy-for-anesthesia-practices/

The Importance of Hospital Coding: Maximizing Reimbursements and Compliance

Ensuring accurate coding and compliance not only reflects your patients’ diagnoses and care but encourages your facility to exceed revenue performance goals.

Many hospitals don’t have the expertise, manpower, or time to establish coding compliance and an efficient workflow. Partnering with a revenue cycle management expert with industry experience and advanced technology can help boost your reimbursements and strengthen your hospital’s compliance.

The Role of Hospital Coding in Revenue Cycle Management

Hospital billing and coding serve as the backbone of revenue cycle management. Medical coding translates medical services, diagnoses, procedures, and equipment into a set of universal medical alphanumeric codes used for claims submission and reimbursement. It ensures hospitals and healthcare providers are reimbursed for services delivered. Coding, claims processing, and collection are all crucial revenue-generating operations for any hospital. 

Understanding the Impact of Accurate Coding on Reimbursements

Accurate coding in hospitals leads to clean claims, faster reimbursements, and a positive bottom line. Medical codes are used to support the claims sent to a patient’s insurance provider, and claims paid by patients and/or insurance companies drive the financial operations of medical organizations. 

But depending on the nature of the patient’s diagnosis and treatment, reimbursement can take weeks or months to be processed. This is why submitting the correct codes the first time around is necessary to get paid as quickly as possible. It also means that coding errors can lead to delayed payments or lost revenue.

Common Challenges in Hospital Coding and Their Effects on Reimbursements

Some of the challenges in coding for hospitals include:

• Incorrect/missing documentation – failing to provide accurate and complete documentation can result in the loss of codable components, leaving room for coding inconsistencies and decreasing your billable expense reimbursements.
• Changes in healthcare regulations and compliance standards – regulations constantly change in healthcare. Failing to stay current with these changes can lead to claim denials, payment delays, and poor cash flow.
• Coding errors – using the wrong codes puts your billing department into a repetitive cycle of claims submission, denial, correction, and payment delays, which throws a wrench into your revenue flow.
• Coding that is too general – this means taking accurate notes and abstracting all relevant information from medical reports. This process requires meticulous attention to detail. When coding is too general, hospitals miss opportunities to collect additional revenue. It also increases the likelihood of claim denials.

Strategies for Optimizing Accuracy and Efficiency

Here are three actionable tips to improve coding accuracy and efficiency:

• Leverage technology – electronic health records (EHR) bring the paper-heavy billing process into the digital age, while computer-assisted coding (CAC) helps analyze documents to identify the right medical codes for clinical documentation. These tools speed up the coding process and increase accuracy and efficiency.
• Perform regular audits – regular audits bring issues to the forefront, so you can address them promptly. Sharing learnings and feedback with coders and providers helps improve operations and coding accuracy.
• Outsource your coding – partnering with hospital billing and coding experts who work exclusively for revenue cycle management providers helps guarantee that claims are filed accurately. They can focus and pay attention to details that medical office staff may overlook in the flurry of their daily tasks and core responsibilities.

The Benefits of Proper Hospital Coding

Proper medical coding is useful for hospitals in the following ways:

• It helps ensure full reimbursement – insurance companies and other healthcare payers rely on hospitals to accurately and completely describe medical tests, procedures, and devices provided for patients. Accurate coding means getting reimbursed in a timely manner. 
• It improves patient safety – proper coding helps assess a patient’s health, identify issues in healthcare quality, and influence new and changing health policies. 
• It improves patient satisfaction – accurate hospital coding simplifies bills and helps patients understand their bills better. When billing is simplified, patients are more likely to pay quickly.

Improved Revenue Capture and Reporting

By implementing hospital coding and billing strategies, your hospital can significantly improve the efficiency and accuracy of its revenue cycle. You can minimize denials, reduce the need for time-consuming appeals, and optimize your revenue capture, leading to operational efficiency that boosts your bottom line.

Improved reporting also allows you to assess your organization’s current health by identifying errors that may occur throughout the billing process. Correcting those errors through proper reporting can reduce expenses from investigations and denied claims and, ultimately, optimize your revenue cycle from beginning to end.

Coronis Health is more than a medical billing company. We offer end-to-end revenue cycle management services that scale with your hospital. We act as your partner and help optimize your coding practices to improve the overall health of your revenue cycle. 

To learn more about hospital medical billing and how outsourcing can benefit your organization, schedule a 1:1 executive consultation with Coronis Health. 

from
https://www.coronishealth.com/blog/the-importance-of-hospital-coding-maximizing-reimbursements-and-compliance/

2024 IPPS Final Rule: Quality Programs

Over the last two weeks, we have provided the latest provisions arising from the 2024 Inpatient Prospective Payment System (IPPS) final rule released earlier this month by the Centers for Medicare and Medicaid Services (CMS). This alert will act as our final installment on the IPPS rule and will specifically focus on the CMS quality programs applicable to the inpatient hospital setting. Those provisions are summarized in a fact sheet also published by CMS, the highlights of which we have provided below.

Hospital Inpatient Quality Reporting Program

The Hospital IQR Program is a pay-for-reporting quality program that reduces payment to hospitals that fail to meet program requirements. Hospitals that fail to submit quality data or to meet all Hospital IQR Program requirements are subject to a one-fourth reduction in their Annual Payment Update under the IPPS.

The 2024 IPPS final rule (a) adopts three new measures, (b) removes three existing measures, and (c) modifies three current measures. The rule also finalizes two changes to current policies related to data submission, reporting and validation.

Specifically, CMS is adding three new electronic clinical quality measures (eCQMs) to the inventory of eCQMs from which hospitals can select to meet the eCQM reporting requirements for a given year for both the Hospital IQR and Medicare Promoting Interoperability Programs:

• Hospital Harm — Pressure Injury eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.
• Hospital Harm — Acute Kidney Injury eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.
• Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level — Inpatient) eCQM, with inclusion in the eCQM measure set beginning with the CY 2025 reporting period/FY 2027 payment determination.

In addition, CMS is finalizing modifications to three current measures:

• Hybrid Hospital-Wide All-Cause Risk Standardized Mortality measure beginning with the FY 2027 payment determination. CMS is finalizing a modification to include Medicare Advantage (MA) admissions.
• Hybrid Hospital-Wide All-Cause Readmission measure beginning with the FY 2027 payment determination. CMS is finalizing a modification to include MA admissions.
• COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure beginning with the FY 2025 payment determination. The prior version of this measure reported on the primary vaccination series only, while the updated version of the measure reports the cumulative number of HCP who are up to date with recommended COVID-19 vaccinations to align CMS programs with the Centers for Disease Control and Prevention’s (CDC’s) definition of “up to date” vaccination, keeping the measure relevant if future vaccination guidance evolves. This measure modification is a cross-program change for the Hospital IQR Program, PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, and the Long-Term Care Hospital Quality Reporting Program (LTCH QRP).

The final rule removes three measures:

• Hospital-level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty measure beginning with the April 1, 2025, through March 31, 2028, reporting period/FY 2030 payment determination. CMS is finalizing removal of this measure under the Hospital IQR Program in conjunction with the adoption of the recent updates to this measure in the Hospital Value-Based Purchasing Program.
• Medicare Spending Per Beneficiary (MSPB) Hospital measure beginning with the CY 2026 reporting period/FY 2028 payment determination. CMS is finalizing removal of this measure under the Hospital IQR Program in conjunction with the adoption of the recent updates to this measure in the Hospital Value-Based Purchasing Program.
• Elective Delivery Prior to 39 Completed Weeks Gestation: Percentage of Babies Electively Delivered Prior to 39 Completed Weeks Gestation measure beginning with the CY 2024 reporting period/FY 2026 payment determination. CMS is finalizing the removal of this measure because measure performance is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made.

CMS is finalizing updates to the data submission and reporting requirements for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measure beginning with the CY 2025 reporting period/FY 2027 payment determination. These updates include three new web-first modes of survey implementation, removal of the survey’s prohibition on proxy respondents, extension of the data collection period from 42 to 49 days, limiting the number of supplemental survey items to 12, requiring the official Spanish translation for Spanish language-preferring patients, and removing two administration methods that are not used by participating hospitals. In a 2021 mode experiment, these changes, which are also being made in the Hospital VBP and PCHQR Programs, resulted in higher response rates and better representation of younger, Spanish language-preferring, racial and ethnic minority, and maternity care patients.  

Medicare Promoting Interoperability Program

CMS is finalizing the following changes to the Medicare Promoting Interoperability Program for eligible hospitals and CAHs:

• Modify requirements for the Safety Assurance Factors for EHR Resilience (SAFER) Guides measure to require eligible hospitals and CAHs to attest “yes” to having conducted an annual self-assessment of all nine SAFER Guides at any point during the calendar year in which the EHR reporting period occurs, beginning with the 2024 reporting period.
• Amend the definition of “EHR reporting period for a payment adjustment year” for participating eligible hospitals and CAHs to define the EHR reporting period in CY 2025 as a minimum of any continuous 180-day period within CY 2025.
• Amend the definition of “EHR reporting period for a payment adjustment year” such that eligible hospitals that have not successfully demonstrated meaningful EHR use in a prior year will not be required to attest to meaningful use by October 1st of the year prior to the payment adjustment year, beginning with the 2025 reporting period.
• Modify the response options related to unique patients or actions for objectives and measures for the Medicare Promoting Interoperability Program for which there is no numerator and denominator, and for which unique patients or actions are not counted. The response option for these would read “N/A (measure is Yes/No).”
• Adopt three new eCQMs eligible hospitals, and CAHs can select as one of their three self-selected eCQMs, in alignment with the Hospital IQR Program, beginning with the CY 2025 reporting period:
  • Hospital Harm — Pressure Injury eCQM
  • Hospital Harm — Acute Kidney Injury eCQM
  • Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level — Inpatient) eCQM

Hospital Value-Based Purchasing (VBP) Program

The Hospital VBP Program is a budget-neutral program funded by reducing participating hospitals’ base operating DRG payments each fiscal year by two percent and redistributing the entire amount back to the hospitals as value-based incentive payments. In the FY 2024 IPPS final rule, CMS is finalizing the proposals to:

• Adopt the Severe Sepsis and Septic Shock: Management Bundle measure in the Safety Domain beginning with the FY 2026 program year.
• Adopt a health equity scoring change for rewarding excellent care in underserved populations such that a health equity adjustment would be added to hospitals’ Total Performance Scores (TPS) based on both a hospital’s performance on existing Hospital VBP Program measures and the proportion of individuals with dual eligibility status that a hospital treats. As a result, CMS is also finalizing the proposal to modify the TPS maximum to 110, such that the numeric score range would be 0 to 110.
• Adopt substantive measure modifications to the MSPB Hospital measure, allowing readmissions to trigger new episodes, beginning with the FY 2028 program year.
• Adopt substantive measure modifications to the Hospital-level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty, adding additional mechanical complication ICD-10 codes to the measure, beginning with the FY 2030 program year.
• Adopt changes to the data submission and reporting requirements of the HCAHPS survey measure beginning with the FY 2027 program year.
• Codify the measure removal factors, the health equity scoring change and modification of the TPS numeric score range, and the minimum number of cases.

The full provisions of the final rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/2023-16252/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the.

To read an earlier alert regarding the 2024 IPPS Final Rule, click here.

With best wishes,

Chris Martin
Senior Vice President—BPO

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

4 Key Performance Indicators for Physician Practices

Key performance indicators (KPIs) offer physician practices a calibrated lens to gauge progression, pinpoint expansion opportunities, and illuminate areas primed for optimization or adjustments. 

These metrics act as the compass within the intricate landscape of healthcare management, navigating your course toward refined patient care, operational prowess, and continuous advancement. In this area of healthcare, KPIs a necessity, not a novelty. The challenge lies in selecting the pertinent measures that meet your practice’s distinct objectives and allow for data-driven decision-making.

Why Key Performance Indicators Matter for Physicians

Key performance indicators are measuring tools used to determine how a business performs in the long term. By measuring KPIs and benchmarking against other practices, you can better understand where you can improve and sustain excellence –because achieving profitability for your practice is more than just setting a list of goals. It requires strategic planning, tracking measurable KPIs, and taking action to adjust when needed.

Top Key Performance Indicators for Physicians

Improving on the following key performance indicators enables your practice to increase operational efficiency and, revenue, and patient satisfaction:

Marketing Metrics

Marketing strategies should be geared not just toward driving patient volume but include patient retention too. Most of your marketing metrics boil down to what you want a patient or potential patient to do (e.g., click, call, or book).

Examples of KPIs that focus on marketing and help your business grow are:

• Search engine optimization (SEO) rankings/position
• Social media metrics (number of followers and number/type of engagements for each social media platform)
• Website performance (demographics, page views, and conversion rates)
• Average star rating, patient review volume, and patient review frequency

Operational Metrics

To successfully manage and grow you practice like a well-oiled machine, look beyond patient growth and measure your operational efficiency. 

By evaluating the four operational metrics below, alongside levering technology in your practice, you can improve your workflow and efficiency by reducing no-shows, saving staff time, and providing a user-friendly platform for patients to book or reschedule appointments.

• Staff metrics (evaluate staff-to-patient and provider-to-staff ratios)
• Patient waiting time
• No-show rate
• Percentage of patients who don’t book follow-up appointments

Patient Satisfaction and Retention Metrics

Healthcare facilities and practices are in the business of customer service, and patient satisfaction is a clear indicator of the quality of your care. 

How your patients perceive the healthcare experience includes wait times, test turnaround time, and overall quality of care. By issuing surveys and questionnaires, your practice can find actionable insights about patient safety and level of care, including broader matters such as budget allocation, bonuses, and incentives for your staff. 

In addition to maintaining your current patient base, attracting new patients and ensuring they return are effective strategies for creating a thriving practice. You can track patient volume, lead conversion, and overall patient satisfaction when you measure the following:

• Total number of patients annually
• Number of new patient appointments 
• Number of return patient appointments per month
• Percentage of website visits converted to new patient appointments
• Patient satisfaction with the quality of care
• Patient satisfaction with length of stay
• Average satisfaction rate

Financial Metrics

Your total revenue measures what happens when your patients visit your practice –and whether they return or not. Consistently declining total revenue signals one or more problems to address, ranging from issues in patient billing and collections to the need for improving patient engagement and attracting new patients.

The numbers you need to measure include:

• Gross profit/net income – this reflects the proceeds that are available for reinvestment or to share with other stakeholders, and it is also a clear indicator of your practice’s financial health. In other words, this is how much money is left over after paying the costs of running your practice. Tracking your gross profits helps your practice determine whether your cash flow allows you to invest in new technologies and talents.
• Average profit per visit – this measures the average revenue from each patient visit. It tells you what income you can expect as the patient volume increases or decreases. It also measures your capacity to serve patients. 
• Cost per visit – this allows you to calculate the net revenue per patient visit by determining how overhead expenses (e.g., salaries or rent/mortgage payments) average out across the number of patients. This number provides insight into your profits and enables you to adjust your budget for other costs aside from supplies and salaries.

Hit Every KPI by Partnering with Revenue Cycle Management Thought Leaders

When you work with revenue cycle management thought leaders, you have access to cutting-edge technology and industry experts that can enhance your collections and streamline data-driven processes to put you on the path toward financial success and independence. 

At Coronis Health, we have decades of experience in billing services and revenue cycle management. We understand the competitive healthcare landscape and can provide the best tools to get you to the next level. With our complimentary revenue cycle management analysis, you gain the business intelligence needed to ensure you beat every benchmark and achieve financial prosperity.

To learn more, schedule a complimentary financial health checkup with Coronis Health today.

from
https://www.coronishealth.com/blog/4-key-performance-indicators-for-physician-practices/

Anesthesia Revenue Opportunities

Summary

It takes a certain level of financial resources and other inducements to attract and retain quality anesthesia providers. Because of these pressures on a practice, many have looked for ways to enhance their groups’ revenue streams. Today’s article explores these other revenue opportunities. 

By far, the greatest challenge facing most anesthesia practices today is the ability to generate enough revenue to recruit and retain a sufficient staff of qualified providers to meet the clinical and coverage requirements of the facilities they serve. It is the economic reality of today’s market that has made it necessary for most practices to request significant financial support from hospital administrations; fee for service collections simply do not generate enough revenue to cover the growing cost of anesthesiologists and CRNAs.

As a result of such financial challenges, many anesthesia practices have been exploring potential sources of additional revenue. As the nation’s largest provider of billing and management services to anesthesia practices, our staff has been monitoring the various initiatives and evaluating their success. Unfortunately, given the nature of the specialty, viable options are quite limited.

Bring on the Blocks

One of the most successful enhancements to the traditional scope of services has been the use of nerve blocks for acute, post-operative pain management. Virtually all insurance plans recognize the value of interscalene, femoral, sciatic and TAP blocks. Up until last year, they even made separate payment for the use of ultrasonic guidance (USG) in connection with these blocks (although, as of January 1, 2023, payment for USG is now bundled into the payment for the most common blocks).

For most practices, the employment of pain blocks has resulted in additional revenue for a variety of orthopedic cases. Many even perform TAP blocks for certain abdominal procedures. As is so often the case, though, now that the use of nerve blocks has become the norm, one can only wonder how long it will be before this revenue source is cut off.

Places of Service

A significant percentage of practices have tried to expand their scope of coverage to a variety of additional venues, including other hospitals, surgery centers and doctors’ offices. Such expansion can require a significant modification of the basic practice model. Meeting staffing requirements of the coverage and call requirements of a hospital can be challenging in itself, but having to schedule and coordinate staff among a variety of outlying venues inevitably involves the creation of a team of schedulers and potentially new software applications.

The ultimate challenge is always the evaluation of the profitability of each of these new venues. What might first seem like a logical way to deploy manpower more effectively can often become a financial loss leader. Practices that expand successfully are constantly monitoring the profitability of each venue so they can pull out of those that do not enhance the overall financial picture of the practice.

Chronic Pain Component

A team of chronic pain management specialists has become an integral part of many practices, but the jury is still out on its true value to an anesthesia practice. The management requirements of chronic pain are completely different from those of an anesthesia practice.

What makes some chronic pain practices so successful is their entrepreneurial spirit that may not be consistent with the philosophy and objectives of an anesthesia practice that is essentially captive to the contractual requirements of a hospital contract. Many a group of chronic pain specialists has broken off from the original anesthesia practice once they realized their true business potential. It should also be noted that, from a billing perspective, a chronic pain practice poses numerous unique challenges.

Exploring Ketamine Clinics

A small number of practices are attempting to explore the potential of the anesthetic agent Ketamine as a treatment option for chronic depression. This is another example of a very creative alternative.

While innovation is often the key to success in business and is often at the core of key developments in medicine it is the rare inventor who actually changes the world. It turns out that what today’s anesthesia practices really need to focus on is not finding new sources of revenue but ways to use the existing revenue more effectively. Appropriate staffing and cost management are the real keys to success in the current environment.  

If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/anesthesia-revenue-opportunities/

2024 IPPS Final Rule: Special Rules for Special Hospitals

There is a scene in the movie Tora, Tora, Tora where a group of sailors on a Japanese aircraft carrier excitedly gather around one of their celebrated pilots. When asked by one of the flight crew, “how did you rate another promotion,” the cocky pilot wryly remarked, “special people deserve special treatment,” which brought roars of laughter from his admirers.

Sometimes, special people, special situations and special institutions do require special consideration. The normal rules don’t always apply. This is the case for specially designated hospitals in the United States. Due to their unique status, special rules apply to them that don’t apply to the standard acute care hospitals. It is the purpose of this alert to address those provisions found in the recently released 2024 Inpatient Prospective Payment System (IPPS) final rule that are particularly applicable to hospitals of special designation. Below, are a few highlights arising from the rule, which originate, in part, from a fact sheet on the final rule released by CMS.

Low-Wage Index Hospitals

The Centers for Medicare and Medicaid Services (CMS) will continue its temporary policies that were finalized in the FY 2020 IPPS final rule to address wage index disparities affecting low-wage index hospitals, which includes many rural hospitals. The rule explains that CMS only has one year of relevant data (from FY 2020) that could be used to evaluate any potential impacts of this policy. Since CMS does not have sufficient data from the time period this policy has been in effect, it was determined to continue the policy while the agency obtains and reviews additional data.

Rural Emergency Hospitals

As you will recall, rural emergency hospitals (REHs) exist as a new CMS hospital classification. The REH designation was established by the Consolidated Appropriations Act (CAA) of 2021 to address the growing concern over closures of rural hospitals. The 2024 final rule includes changes to graduate medical education (GME) payments for training relative to REHs. These changes help support graduate medical training in rural areas by allowing these rural hospitals to serve as training sites for Medicare GME payment purposes after they become REHs.

Rural Wage Index Calculation

CMS has taken into consideration recent public comments that have urged it to change its wage index policies involving the treatment of hospitals that have reclassified from urban to rural under section 1886(d)(8)(E) of the Social Security Act (implemented in the regulations at §412.103). The rule finalizes the proposal to interpret section 1886(d)(8)(E) of the Social Security Act as treating rural reclassified hospitals the same as geographically rural hospitals for purposes of calculating the wage index. Specifically, CMS will include hospitals with §412.103 reclassification along with geographically rural hospitals in rural wage index calculations beginning with FY 2024. Under Section 4410(a) of the Balanced Budget Act of 1997 (Pub. L. 105–33), the area wage index applicable for any hospital that is located in an urban area of a state may not be less than the area wage index applicable to hospitals located in rural areas in that state. This provision is referred to as the rural floor. CMS will include the data of all §412.103 reclassified hospitals in the calculation of the wage index for the rural area of the state and the calculation of the rural floor for urban hospitals in the state.

Disproportionate Share Hospitals

As you’ll recall from last week’s alert the 2024 IPPS final rule contained a 3.1 percent payment increase for hospitals that meet quality and reporting requirements for FY 2024, up from the 2.8 increase that had been recommended in the proposed rule. This represents an increase in inpatient hospital payments of $2.2 billion compared to FY 2023. However, Disproportionate Share Hospital (DSH) payments will actually decrease by $957 million, according to the final rule, and CMS is projecting payments for new medical technologies will also decrease by $364 million.

The cut to DSH payments is based, in part, on an Office of the Actuary estimate that 8.5 percent of individuals will be uninsured in calendar year (CY) 2024, compared to 7.7 percent in CY 2023. According to some, this estimate is somewhat problematic. For example, in a statement released by the American Hospital Association (AHA) on August 1, the cuts were described as “inexplicable” in light of recent plunges in Medicaid enrollment.

Physician-Owned Hospitals

For a hospital to submit claims and receive Medicare payment for services referred by a physician owner or investor (or a physician whose family member is an owner or investor), the hospital must satisfy all of the requirements of either the whole hospital exception or the rural provider exception to the physician self-referral law, commonly referred to as the “Stark Law.”

To use the rural provider exception or the whole hospital exception, a hospital may not increase the aggregate number of operating rooms, procedure rooms, and beds above that for which the hospital was licensed on March 23, 2010 (or, in the case of a hospital that did not have a provider agreement in effect as of that date, but did have a provider agreement in effect on December 31, 2010, the effective date of such agreement), unless CMS has granted an exception to the prohibition on expansion. A hospital may request an exception to the prohibition on expansion of facility capacity using the process established in the 2012 Hospital Outpatient Prospective Payment System (OPPS) final rule.

The final rule accomplishes the following:

• Revises the regulations to clarify that CMS will only consider expansion exception requests from eligible hospitals, clarifying the data and information that must be included in an expansion exception request, identifying factors that CMS will consider when making a decision on an expansion exception request, and revising certain aspects of the process for requesting an expansion exception. 
  
• Reinstates, with respect to hospitals that meet the criteria for “high Medicaid facilities,” program integrity restrictions on the frequency of expansion exception requests, maximum aggregate expansion of a hospital, and location of expansion facility capacity that were removed in the CY 2021 OPPS final rule. 

Cancer Hospitals

The PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program is a quality reporting program for the eleven cancer hospitals that are statutorily exempt from the IPPS. CMS collects and publishes data from PCHs on applicable quality measures. The final rule sets forth the following:

• Beginning public display of the Surgical Treatment Complications for Localized Prostate Cancer measure beginning with data from the FY 2025 program year.
• Adoption of four new measures for the PCHQR Program:
• Facility Commitment to Health Equity beginning with the FY 2026 program year. 
• Screening for Social Drivers of Health beginning with voluntary reporting for the FY 2026 program year and mandatory reporting for the FY 2027 program year.
• Screen Positive Rate for Social Drivers of Health beginning with voluntary reporting for the FY 2026 program year and mandatory reporting for the FY 2027 program year.
• Documentation of Goals of Care Discussions Among Cancer Patients beginning with the FY 2026 program year.
• Modification of the COVID-19 Vaccination Coverage among HCP measure, in alignment with the Hospital IQR Program and LTCH QRP.
• Modification of the data submission and reporting requirements for the HCAHPS survey measure beginning with the FY 2027 program year.

Next week, we will conclude our review of the final rule by focusing on the hospital quality program.

To read more on the 2024 IPPS Final Rule, read one of our earlier alerts here.

With best wishes,

Chris Martin
Senior Vice President—BPO

from
https://www.coronishealth.com/blog/2024-ipps-final-rule-special-rules-for-special-hospitals/

No Surprises Act Update: HHS on the Losing Side Again

Summary

The back-and-forth battle between the Texas Medical Association and the federal government over the implementation of the No Surprises Act has led to yet another court decision against the government. The result is a dramatic drop in the independent dispute resolution fee amount—at least for now.

You know you’re having a bad day when you’ve just lost your third lawsuit in a row to the same group of plaintiffs. That’s especially irksome when you represent the almighty federal government and you’ve just been beaten again by a group of Texas doctors. So much for not being able to successfully fight city hall.

The context of this series of legal contests lies in the No Surprises Act (NSA), which became national law on Jan. 1, 2022. It established a federal framework for protecting in-network patients from being balance billed by out-of-network medical providers in an otherwise in-network facility. It also contained certain safeguards for self-pay and uninsured patients, such as requiring doctors and other billing practitioners to provide such patients with a good faith estimate (GFE) of the cost of the service prior to surgery.

Leadup to the Latest

One of the provisions of the NSA involves the establishment of a mediation system that the aforementioned non-participating providers can access when they believe that insurance companies have not provided them with reasonable reimbursement for services rendered. The independent dispute resolution (IDR) process allows either party to bring their complaint to a government-certified IDR mediator to make a final determination as to the appropriate payment for the medical service in question.

But, of course, going down the IDR route would not be free. In the original regulatory provision addressing the cost of the IDR process, the administrative fee for each party was set at $50. But, months later, the Centers for Medicare and Medicaid Services (CMS) increased this fee to $350, reflecting a 600 percent increase. The Texas Medical Association (TMA), which had previously brought successful suits against the U.S. Department of Health and Human Services (HHS) and CMS for what it believed to be improper NSA regulations, decided it was time to take action once more against what they felt was the latest example of government overreach.

In their January 2023 lawsuit, the TMA alleged that the change in the IDR fee “not only will make the process significantly more expensive for all IDR participants but will make it cost-prohibitive for many providers to access IDR at all.” It now appears that a federal court is singing from the same songbook.

Bringing Down the Gavel

On August 3, a judge for the U.S. District Court for the Eastern District of Texas held that HHS acted improperly when it failed to follow “notice and comment” requirements prior to its announcement of the IDR fee increases. As a result, the $350 fee was vacated by the court.

In its suit, the TMA had also disputed interim final rules that narrowed the NSA’s stipulations on “batching” claims for arbitration. The plaintiffs asserted that Congress had authorized batching to encourage efficiency and minimize costs in the IDR process and that the interim final rules had undercut this legislative intent. In his ruling, Judge Jeremy Kernolde invalidated the agency’s attempt to narrow the batching of claims.

As a result of these determinations by a federal court, the IDR process was suspended until federal agencies were able to provide additional instructions commensurate with the August 3^rd decision. The interested parties wouldn’t have to wait long to hear from the government.

The Government’s Response

In the wake of this latest federal court ruling, CMS issued a set of FAQs on August 11 as a means of providing interim guidance on the IDR process. According to the FAQs, the administrative fee for disputes that were initiated or unpaid on or after August 3 will be $50 per party until the federal departments take action on a new fee amount. For disputes initiated between January 1 and August 2 that have been paid, the fee remains $350. The judge’s order does not require a refund on administrative fees paid before Aug. 3.

Following the judge’s ruling, HHS said it temporarily suspended the initiation of new IDR actions until the federal agencies can provide additional instructions. CMS said the federal departments tasked with overseeing the IDR process “intend to reopen the portal to permit the submission of new disputes soon and will notify interested parties at that time.”

So, what are the takeaways regarding the government’s response to its latest legal defeat? First, we are faced with yet another period of “interim” rules while the government regroups to find a more permanent fix. In other words, more rulemaking is on the way. Second, even though the court vacated the $350 IDR fee, that doesn’t mean we’re back to $50 fees forever. The government said it is in the process of deciding a “new fee amount.” It will be interesting to see if the government’s response to all this will be to simply follow the notice and comment requirements in connection with a new announcement of the same $350 fee amount. After all the court’s decision to strike down the fee was based on the government’s failure to follow this technicality. So, HHS may be thinking, “all we’ve got to do is dot this “i” and cross this “t” and we’re back in business again”—that is, until the next legal challenge from Texas.

We will keep you apprised of the next developments in this ongoing story. Until then, you can access the full set of CMS’ FAQs by going to the following link: IDR Admin Fees FAQs (cms.gov). If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

from
https://www.coronishealth.com/blog/no-surprises-act-update-hhs-on-the-losing-side-again/