|The Stark Reality of Physician Reimbursement |
By Mark Isenberg, EVP, Health Advocacy, Zotec Partners |August 24, 2022
The Centers for Disease Control and Prevention (CDC) defines health equity as, “Every person having the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.” It is indeed a noble pursuit, but without access to qualified physicians financially able to provide services to underserved populations, it is nothing more than a myth. Today, physicians are managing the business of healthcare with the deck stacked against them. Just months after being lauded as heroes for their efforts in the pandemic, they are being rewarded by significantly reducing their ability to maintain a private independent practice. They are not just fighting to save lives but fighting to keep their practices afloat.
Decreasing Medicare reimbursement, declining commercial rates, inflation, and the ever-changing “quality” metrics that physicians are forced to comply with are leading to burnout, retirement, change of profession, consolidation, and an overall strain on our healthcare system.
Reality of Medicare Cuts and Inflation Rates
The 2023 Medicare Physician Fee Schedule Proposed Rule poses a significant reduction in Medicare reimbursement for many clinicians, including:
Cut of approximately 4.42% to the conversion factor (containing a Congressional one-time boost of 3% for 2022).
Reduction to the fee schedule and an outstanding threat of the 4% PAYGO decrease.
End of the 2% sequestration moratorium in 2022.
Collectively, this could create double-digit cuts if no action is taken.
You can take action now by contacting your representatives and senators.
To read more, go to Becker’s Hospital Review.
|Insured Patients Become Top Reason for Bad Debt at Providers |
By Caroline Hudson | August 23, 2022
The amount of bad debt stemming from patients with insurance increased more than five-fold in a three-year period, hitting providers’ financial statements in an already challenging environment.
Almost 58% of patient bad debt in 2021 came from self-pay accounts after insurance, compared with about 11% in 2018, according to a recent study from professional services firm Crowe. Self-pay accounts after insurance include the deductible and amount due after the insurance payment.
Most bad debt, or write-offs associated with patient balances deemed uncollectible after significant collection efforts, once was tied to uninsured patients. Discounts implemented for the uninsured have helped curb those balances in the last several years, said Brian Sanderson, a principal in Crowe’s healthcare consulting group.
Health systems are navigating rising costs in the face of fewer payments from patients who are increasingly turning to high-deductible plans they can’t afford.
Average patient balances had been on the upswing before the COVID-19 pandemic, Sanderson said. The public health crisis made matters worse because of disruptions in staffing and patient volume. Patients also sought more treatment for mild symptoms, such as coughing or a runny nose, that were not a cause for alarm prior to the pandemic, driving up their medical bills. “
More people were accessing the healthcare system at the same time that the healthcare system was very challenged to both treat them and (was) probably overly aggressive at the outset in terms of clinical spend on things,” Sanderson said.
The Crowe study found $7,500 to be the threshold at which collections dropped off on self-pay patient accounts. Statement balances greater than $7,500 made up 17.7% of total statements in 2021–triple the proportion in 2018. Balances greater than $14,000 accounted for 16.8% of total statements in 2021, compared with 4.4% in 2018, according to the study. Sanderson said the rise of high-deductible plans has made it more difficult for patients to pay their healthcare bills, as those plansshift much of the cost burden to patients. Many employers offer high-deductible plans to lower their overall benefits costs, and employees pay lower premiums.
To read more, go to Modern Healthcare.
|Researchers Examine Growth of Nonphysician Practitioners in Radiology |
By Hannah Murphy | August 22, 2022
The presence of physician assistants and nurse practitioners has grown significantly over the last decade, but how have their roles in the field of radiology evolved during this time?
A new paper published Aug. 22 in the Journal of the American College of Radiology digs deeper into this emergence of nonphysician practitioners (NPPs) and how it has impacted clinical, procedural and imaging interpretation volumes in radiology settings . This included an analysis of Medicare claims involving NPPs from 2017 to 2019. Experts weighted the NPP services by work relative value units and then categorized them as clinical evaluation and management (E&M), invasive procedures or noninvasive imaging interpretation.
Corresponding author Stefan Santavicca, MS, of the Department of Radiology and Imaging Sciences at Emory University School of Medicine and colleagues uncovered a 16.3% increase in radiologist employed NPP Medicare claims during the study period. This resulted in a 17.3% increase of aggregate Medicare fee-for-service work relative value units. NPPs completing clinical evaluation and management, invasive procedures and imaging interpretation increased by 7.6%, 18.3% and 31.8%, respectively.
To read more, go to Health Imaging.
|ACR, Other Groups Cry Foul Over Insurers’ Methods for Calculating Out-of-network Payments |
By Dave Pearson | August 19, 2022
More than two-thirds of primary care professionals have contracts with insurers covering services, including advanced-imaging procedures, that they rarely if ever perform.
More than half the field contracts for services they don’t supply at all. Frustratingly for radiology—along with anesthesiology, emergency medicine and likely other specialties—insurers have been using the primary-care rates to calculate national Qualifying Payment Amounts (QPAs) for out-of-network transactions.
More to the point, they’ve been factoring in the lowball prices to justify underpaying specialists for their expertise. They’re likely emboldened to do so by Congress’s decision to let insurers set their own out-of-network rates, albeit with dispute arbitration supplied by independent contractors.
The dynamics are out in the open now thanks to a survey and analysis commissioned by the American Society of Anesthesiologists (ASA), American College of Emergency Physicians (ACEP) and American College of Radiology.
Flagging survey findings for public scrutiny, the ACR says insurers using primary-care rates to pay specialists may be doing so in violation of the No Surprises Act.
“Despite the law’s directive that QPA calculation be based on payment data from the ‘same or similar specialty’ in the same geographic region, insurers may be calculating median in-network rates for specialty services using PCP contracted rates for services that were never negotiated, may never be provided by those physicians and may never be paid,” the ACR states in a news release posted Aug. 17. “This method may violate the law and produce insurer-calculated QPAs that do not represent typical payments for these services.”
To read more, go to Radiology Business.
|HHS and Federal Departments Issue Final Rules to Clarify No Surprises Act Dispute Resolution |
By Susan Morse | August 19, 2022
The U.S. Departments of Labor, Health and Human Services, and the Treasury have issued final rules concerning standards related to the arbitration process in implementing the No Surprises Act.
The final rules aim to clarify the process for providers and health insurance companies to resolve their disputes, the departments said in a Friday release.
WHY THIS MATTERS
Importantly for hospitals, the final rules reflect a District Court ruling vacating a portion of the October 2021 interim final rules that required Independent Dispute Resolution entities to select the offer closest to the Qualified Payment Amount.
This process favored insurers; hospitals argued.
The District Court vacated this requirement in rulings in February and July.
The final rules specify that certified IDR entities should select the offer that best represents the value of the item or service under dispute after considering the Qualified Payment Amount (QPA) and all permissible information submitted by the parties.
The departments are adding a definition for the term “downcode” to require additional information from the insurers about the QPA. This must be provided with an initial payment or notice of denial of payment, without a provider, facility, or provider of air ambulance services having to make a request for this information, in cases in which the plan or issuer has downcoded the billed claim, according to the final rules.
These final rules also specify that, if a QPA is based on a downcoded service code or modifier, in addition to the information already required, a plan or issuer must provide a statement that the service code or modifier billed by the provider, facility, or provider of air ambulance services was downcoded; an explanation of why the claim was downcoded, including a description of which service codes were altered, if any, and which modifiers were altered, added, or removed, if any; and the amount that would have been the QPA had the service code or modifier not been downcoded.
The departments are continuing to consider comments on the July 2021 interim final rules about whether additional disclosures related to the QPA calculation methodology should be required to be provided. In releasing the final rules, the departments said they have received “substantially more” disputed claims than expected. Between April 15 and August 11, disputing parties initiated more than 46,000 disputes through the federal Independent Dispute Resolution portal, which is substantially more than the departments initially estimated would be submitted for a full year.
Of these, certified IDR entities rendered a payment determination in over 1,200 disputes.
THE LARGER TREND
In December 2021, the American Hospital Association and American Medical Association and others sued HHS and the other federal agencies over implementation of the No Surprises Act. The groups were not against the legislation, they said in the lawsuit, but took issue with how HHS implemented the Internal Dispute Resolution process to resolve payment rates between provider and payer. The interim final rule stipulated that the arbitrator must select the offer closest to the Qualifying Payment Amount, which is set by the insurer.
To read more, go to Healthcare Finance.