|CMS Resumes IDR Payment Determinations Under No Surprises Act|
By Jacqueline LaPointe | March 21, 2023
CMS has instructed certified independent dispute resolution (IDR) entities to resume payment determinations for disputes involving items or services furnished on or after Oct. 25, 2022, according to the American Hospital Association (AHA). Payment determinations for the disputes were paused earlier this year after a court rule against the federal agency.
A Texas judge ruled on Feb. 6, 2023, that a revised IDR process skews arbitration results in favor of payers, which violated Congress’ intent for the No Surprises Act. In the ruling, the judge vacated the regulations nationwide.
CMS stopped all payment determinations under the IDR process following the Texas court’s decision. Late last month, certified IDR entities could make payment determinations for disputes involving out-of-network items and services before Oct. 25, 2022, using the standards from October 2021 interim final rules.
This month, CMS dropped additional guidance for payment determinations made on or after Feb. 6, 2023, for items and services furnished on or after Oct. 25, 2022, for plan years beginning on or after Jan. 1, 2022.
The AHA also said CMS announced that starting Mar. 17, 2023, disputing parties will start getting most of their payment determination notices from the IDR portal, specifically from email@example.com.
Professors in a new Health Affairs Forefront blog post say that it remains unclear how the Texas judge’s decision to vacate the IDR regulation will be appealed or what comes next for the process.
“[I]t obviously represents a wild card that could change the IDR balance of power in the direction of providers at the expense of insurers,” wrote research professors Jack Hoadley, PhD, and Kevin Lucia, JD, MHP, from the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy.
Meanwhile, the IDR process is currently facing a backlog. The federal government expected about 22,000 IDR cases for all of 2022, per the interim final rule establishing the process. By the end of September, payers and providers had filed 90,078 cases. A December update notice reported 164,000 cases filed as of Dec. 5, 2022.
The high volume of disputes submitted to the IDR process — even though upwards of 40 percent of disputes are deemed ineligible — could signal provider frustration over payments they receive from payers for out-of-network claims, Hoadley and Lucia state. A recent survey of medical group leaders found that the No Surprises Act is a top source of provider regulatory burden, trailing prior authorizations.
To read more, go to Revcycle Intelligence.
MedPAC Recommended Physician Payment Update
March 21, 2023
The Medicare Payment Advisory Commission (MedPAC) has released its March 2023 reportto Congress on various Medicare Payment Policies. MedPAC analysis found that the current physician payment rate to be inadequate; therefore, it recommended a 1.45% physician payment update for 2024.
MedPAC has recognized that physician pay has not kept up with the cost of practicing medicine. According MedPAC, this update is to come from an update to the Medicare base payment rate by 50 percent of the Medicare Economic Index (MEI). While still insufficient, the recommended update represents the first time in 26 years that MedPAC has recommended a positive update.
The annual report includes MedPAC’s analyses of payment adequacy in traditional fee-for-service (FFS) Medicare and Medicare Advantage (MA) and the prescription drug benefit (Part D).
The report states that Medicare spending is projected to double in the next 10 years due to increase in the number of beneficiaries and increase in the volume and intensity of services delivered per beneficiary. MedPAC expects Medicare spending to grow 4.7% faster than inflation even though the Medicare prices are growing slower than inflation.
MedPAC found that allowed charges per beneficiary fell by 7.3% for anesthesia services between 2019 and 2021. During the same time, the allowed changes for Evaluation and Management (E&M) services increased by 6.1%.
MedPAC also reported that the Medicare Advantage program will cost 6% more per beneficiary compared with traditional Fee for Service (FFS) program. Currently, Medicare Advantage accounts for 41% of Medicare spending and FFS accounts for 48% of Medicare spending.
To read more, go to ASA’s website.
AMA Commends MedPAC for Move to Recognize Costs of Practicing Medicine
March 15, 2023
For the first time, the Medicare Payment Advisory Commission (MedPAC) today called for a physician payment update tied to the Medicare Economic Index (MEI). The American Medical Association (AMA) has long championed this move and appreciates MedPAC’s acknowledgement that the current Medicare physician payment system is inadequate—a critical first step toward the larger, necessary work of reforming Medicare to make it more rational and serve patients better.
In the face of inflation, the COVID pandemic, and growing costs of running a medical practice, physicians have struggled to keep open their doors, jeopardizing access to care, particularly in rural and underserved areas. Not only have Medicare payments failed to respond adequately, but physicians saw a 2% payment reduction for 2023, creating an additional challenge at a perilous moment.
“Having surveyed the health care landscape, MedPAC recognized that physician pay has not kept up with the cost of practicing medicine. Yet, we feel strongly that an update tied to just 50% of MEI will cause physician payment to chronically fall even further behind increases in the cost of providing care. Congress should adopt a 2024 Medicare payment update that recognizes the full inflationary growth in health care costs,” said AMA President Jack Resneck Jr., M.D.
“As one of the only Medicare providers without an inflationary payment update, physicians have waited a long time for this change. When adjusted for inflation, Medicare physician payment has effectively declined (PDF) 26% from 2001 to 2023. These increasingly thin or negative operating margins disproportionately affect small, independent, and rural physician practices, as well as those treating low-income or other historically minoritized or marginalized patient communities. Our workforce is at risk just when the health of the nation depends on preserving access to care.
Medicare reform is a central plank in the AMA Recovery Plan for America’s Physicians.
Also today, the AMA and 134 other health organizations—representing 900,000 physicians and tens of millions of Medicare patients—wrote congressional leaders, telling them that a full inflation-based update is “the principal legislative solution to the ongoing problems plaguing the Medicare Physician Fee Schedule.”
The letter notes that Congress has passed stopgap measures in the past few years to mitigate threats to Medicare physician payments. Yet, practice costs have outpaced those efforts. The gap between frozen physician payment rates and rising medical practice costs due to inflation will continue to widen. A permanent solution is needed to avoid this annual panic and legislative chaos.
To read more, go to AMA’s website.
States Ranked by Number of Practicing Anesthesiologist
By Patsy Newitt | March 14, 2023
California has the most practicing anesthesiologists of any state, according to data collected in January 2023 by the Kaiser Family Foundation.
Here are the number of practicing anesthesiologists in each state:
New York: 4,458
New Jersey: 1,636
North Carolina: 1,169
South Carolina: 627
District of Columbia: 319
New Mexico: 259
West Virginia: 233
New Hampshire: 222
Rhode Island: 138
North Dakota: 76
South Dakota: 70
To read more, go to Becker’s ASC.
Google Ups Activity in 4 Reaches of Healthcare AI
By Dave Pearson | March 14, 2023
Along with expanding research into large-language models to rival OpenAI’s ChatGPT, the search-engine king is working on AI for improving maternal care, ultrasound access and tuberculosis screening.
Google announced the concentrations March 14 in an update posted by Greg Corrado, PhD, the company’s head of health AI, during its annual health event, the Check Up with Google Health.
“We’ve taken a ‘move slow and test things’ approach to prove efficacy, equity, helpfulness and safety above all,” Corrado writes.
In healthcare, he adds, “there is enormous potential for AI to augment diagnostic and treatment planning processes, especially through partnerships to help bring high-quality care to communities that need it most.”
Here’s what Corrado says Google is doing in each of the four healthcare AI realms it’s spotlighting at the Check Up 2023.
Medical large-language models. Google is investing R&D dollars to design applications that maintain the “utmost focus on safety, equity and bias to protect patient well-being,” Corrado shares.
Google’s latest chatbot aimed at informing providers as well as patients is Med-PaLM 2. As the name implies, it’s an updated iteration of Med-PaLM, which last year topped 60% on a quiz styled like a medical-licensing exam.
Corrado says Med-PaLM 2 has upped the ante, consistently supplying correct answers at an 85% clip.
“While this is exciting progress, there’s still a lot of work to be done to make sure this technology can work in real-world settings,” Corrado writes. “We look forward to working with researchers and the global medical community to close [the] gaps [we’ve identified] and understand how this technology can help improve health delivery.”
AI-assisted ultrasound. Google is partnering with Kenya-based Jacaranda Health to train sub-Saharan healthcare workers in the use of maternal-fetal sonography for at-risk women and preborn babies. Concurrently the companies are developing AI tools to support point-of-care ultrasound (POCUS) for this population.
Meanwhile Google is collaborating with a hospital in Taiwan to bring AI-aided breast cancer screenings to Taiwanese women, including those with dense breast tissue, Corrado reports.
“In recent years, sensor technology has evolved to make ultrasound devices more affordable and portable, but many low-resource areas have a shortage of ultrasound specialists,” he points out. “To help bridge this divide, we’re building AI models that can help simplify acquiring and interpreting ultrasound images to identify important information like gestational age in expecting mothers and early detection of breast cancer.”
To read more, go to Health Exec.
Past-Due Medical Debt Impacts Over 1 in 7 Adults
By Jacqueline LaPointe | March 14, 2023
More than one in seven nonelderly adults live in families with past-due medical debt, according to the Urban Institute in a new report.
The report also finds that medical debt particularly impacts low-income families. Nearly two-thirds of adults affected by past-due medical debt have incomes below 250 percent of the federal poverty line, the Urban Institute gleaned from June 2022 data from its Health Reform Monitoring Survey (HRMS).
More of the past-due medical debt is owed to hospitals, with nearly three-quarters of affected adults owing at least some debt to hospitals. More specifically, 28 percent of affected adults owed to hospitals only and 45 percent owed to hospitals and some other providers.
Adults with past-due medical debt to hospitals tended to owe more compared to those with non-hospital medical debt, the report also shows. Additionally, about 61 percent of adults with past-due medical bills to hospitals reported that a collection agency contacted them about the debt.
Under federal law, non-profit hospitals must establish financial assistance policies and provide charity care to eligible patients before attempting to collect patient financial responsibility. However, non-profit hospitals set their own charity care eligibility requirements and many patients who likely qualify per hospital policies do not receive charity care, the Urban Institute points out.
Furthermore, for-profit and public hospitals are not subject to federal laws about medical financial assistance. These hospitals can implement their own strategies for collecting patient financial responsibility, including using a collection agency, filing lawsuits against patients, and even garnishing their wages.
State lawmakers have recently gone after aggressive medical debt collection tactics. New York, for example, modified civil practice law last year to prohibit healthcare providers from placing liens on an individual’s primary residence or garnishing wages to collect medical debt.
The Biden Administration has also acknowledged the problem of medical debt and promised to protect consumers through several reforms, including requesting data from more than 2,000 providers to evaluate medical bill collection practices and financial assistance offerings.
The report from the Urban Institute finds that few adults experience the more aggressive medical debt collection tactics hospitals can use to get their money. Only about 5 percent of adults with hospital debt said a hospital filed a lawsuit against them, while 4 percent said hospitals had garnished their wages and 2 percent said hospitals had seized funds from a bank account.
More adults with past-due hospital debt (36 percent) said they worked out a payment plan. Meanwhile, about one-fifth of adults with past-due hospital bills received discounted care.
To read more, go to Revcycle Intelligence.
Senators Accuse Payers of Evading Price Transparency Rules
By Jakob | March 13, 2023
Two senators are asking CMS to address loopholes in its price transparency rule for payers that they say have allowed the industry to “evade accountability.”
“We are concerned that remaining technical loopholes have resulted in insurance companies publishing data that does not align with the intent of the CMS rule,” Democratic Sen. Maggie Hassan and Republican Sen. Mike Braun wrote March 6.
Since July 1, payers have been required by CMS to disclose in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for all covered items and services.
The lawmakers cited recent reports that say some payers have published data in confusing formats that omit important information. They also said the published data is “too large for anything but a supercomputer to process.” Because of those challenges, it’s difficult to compare health plans and researchers and employers have struggled to use the data to drive lower costs.
According to San Diego-based transparency data startup Turquoise Health, it would take 76,104 decades to count up all the data available in machine-readable files.
“Trying to locate a single provider in the [transparency in coverage] files is akin to trying to find a single word in a very large dictionary that isn’t in alphabetical order,” a January report from Georgetown University said.
“Experts have highlighted potential solutions, urging CMS to limit file sizes, create a standardized reporting template, reduce the frequency of reporting, and require a clear organizational system and standardized labeling,” the senators wrote.
The letter also urges CMS to conduct random audits of health plan data to ensure compliance and quality.
To read more, Becker’s Payer Issues.
How E/M Payment Policy Changes Impacted Physician Reimbursement
By Victoria Bailey | March 8, 2023
Evaluation and management (E/M) payment policy changes implemented in 2021 resulted in higher Medicare reimbursement for most physicians but only led to a modest decrease in the payment gap between primary care and specialty physicians, according to a study published in JAMA.
Medicare payment policies have historically undervalued E/M visits. These visits are common in primary care settings, leading to lower reimbursement for primary care physicians compared to specialists. There have been some concerns that the payment gap is larger than appropriate and may deter physicians from primary care specialties.
In January 2021, CMS increased Medicare reimbursement for E/M services provided by all physicians. The agency also reduced the Medicare conversion factor for all specialties, resulting in reimbursement cuts for non-E/M services.
At the same time, the American Medical Association (AMA) eased documentation requirements for E/M codes and modified time-based billing guidelines, making it easier to bill higher-intensity, more profitable E/M codes.
Researchers conducted an observational study to assess how the E/M payment policy changes impacted Medicare reimbursement and E/M coding intensity among primary care and specialty physicians. In addition, they simulated the volume-constant effect of the policy changes on Medicare payments and compared the simulated changes to the observed changes.
The study used data from July to December 2020, known as the pre-period relative to the policy changes, and July to December 2021, defined as the post-period. The sample included 180,624 office-based physicians who billed Medicare.
Following the E/M policy changes, reimbursement increases for E/M services ranged from 2.3 percent to 23.5 percent.
When repricing services provided in the pre-period at 2021 payment rates, radiology (-3.3 percent), ophthalmology (-2.8 percent), and general surgery physicians (-0.1 percent) lost reimbursement. However, most specialists would have gained revenue, the study found.
The specialty estimated to see the largest gains relative to pre-period payments was primary care, consisting of family practice (11 percent) and internal medicine (10.8 percent). Psychiatry (9.2 percent), neurology (5.7 percent), and obstetrics/gynecology (4.6 percent) followed.
Between July and December 2020, the reimbursement gap between primary care physicians and specialists was $40,259.8. After repricing pre-period services at 2021 rates, the gap narrowed slightly to $37,759.5.
To read more, go to Revcycle Intelligence.
Anti-Anesthesiologist Lawmaker Includes AANA Provision in Rural Health Bill
March 2, 2023
The American Society of Anesthesiologists (ASA) has identified that the “Save America’s Rural Hospitals Act,” or H.R. 833, authored by Rep. Sam Graves (R-MO-06) includes an AANA provision intended to dismantle Medicare’s requirement for physician supervision of nurse anesthetists. Rep. Graves has a long record of opposing safe physician-led models of anesthesia care and supporting nurse-only models. ASA has engaged with the legislative sponsors to express opposition to the provisions and will work to ensure that the AANA’s language in the legislation does not advance this Congress.
ASA has been a long-time supporter of efforts to improve rural access to care, including supporting the Medicare Access to Rural Anesthesiology Act, which would reform the Medicare rural pass-through program to allow rural hospitals to employ or contract with all types of anesthesia providers – physician anesthesiologists, as well as anesthesiologist assistants and nurse anesthetists. This bill has not yet been introduced in the 118th Congress.
To read more, go to ASA’s website.