|Dear Congress: Proposed 2023 MPFS ‘Threatens Access to Life-saving Procedures and Continued Operation of Essential Medical Services’
By Dave Pearson | August 4, 2022
TAKE ACTION NOW! Contact your representatives and senators.
Eight imaging associations concerned about radiology’s fiscal fate at the hands of CMS’s proposed Medicare Physician Fee Schedule for 2023 are imploring Congress to intervene.
In a letter sent this week to the chairs and ranking members of three subgroups—The Senate’s finance committee and the House’s ways & means and energy & commerce committees—leaders of the organizations invoke MACRA, the Medicare Access and CHIP Reauthorization Act of 2015.
That legislation was enacted “to maintain the stability of our healthcare infrastructure in order to ensure access to vital health services, but now the perennial fight to avoid catastrophic damage to clinicians’ ability to provide care has returned,” the authors write.
They state that a cut of approximately 4.5% to the MPFS conversion factor, as CMS is proposing, would hurt providers in its own right. Just as damaging, the authors suggest, the slash would intensify the pressures of a looming 4% pay-as-you-go (PAYGO) reduction and a 2% Medicare sequestration cut intended to align CMS’s budget with across-the-board federal budget constraints.
Together these hits would add up to double-digit drops in dollars for healthcare providers serving Medicare patients, the authors add.
“After enduring a global pandemic, where many providers were forced to cease operations due to restrictions on elective procedures, a subsequent supply chain crisis and the steep increased cost of nearly all aspects of maintaining operations, significant headwinds facing healthcare providers across the country still remain. The latest MPFS proposed rule cuts only will make matters worse and threaten access to life-saving procedures and continued operation of essential services.”
The letter’s signatory organizations are the American College of Radiology (ACR), American Society of Radiologic Technologists (ASRT), Association for Medical Imaging Management (AHRA), Medical Imaging & Technology Alliance (MITA), Radiology Business Management Association (RBMA), Rayus Radiology, Shields Healthcare Group and Society of Nuclear Medicine and Molecular Imaging (SNMMI).
TAKE ACTION NOW! Contact your representatives and senators.
To read more, go to Radiology Business.
|Coming to a Contract Negotiation Near You: The No Surprises Act
By Nona Tepper | August 3, 2022
When Cigna wanted to cut reimbursements for a physician group, the health insurance company came armed with a new negotiating tool: the No Surprises Act.
The insurer notified a clinical practice last week that its contracted rate was no longer competitive because of the federal ban on surprise billing, according to an email provided to Modern Healthcare. Indeed, Cigna wrote, it was requesting rate reductions for all providers with the same specialty.
Cigna regularly reviews contracted rates it deems above-market with an eye toward bringing them down, a spokesperson wrote in an email. And the company doesn’t routinely cite the No Surprises Act as a reason to change payment levels, the spokesperson wrote.
Yet written notices from Cigna and other health insurance companies citing the No Surprises Act indicate that the new law is influencing insurers’ in-network and out-of-network negotiations with providers. Whether that’s a good thing depends on who you ask.
Physicians point to these messages as evidence that health insurance companies are trying to leverage the surprise billing ban to strong-arm them into accepting lower payments. Insurance carriers are seeking pay cuts as high as 50%, American Medical Association President Dr. Jack Resneck Jr. wrote in an email.
“We continue to communicate our concerns to regulators that these payer tactics will lead to inadequate networks or access issues,” Resneck wrote. “The AMA is monitoring this situation and will work relentlessly to beat back these cynical ploys.”
Insurers argue they are working to lower costs for patients, particularly among private equity-owned specialty providers that charge exorbitant rates.
In February, CVS Health’s Aetna refused to pay more than the rate outlined in the No Surprises Act for services the air ambulance company Global Medical Response provides its members, according to a bill the Greenwood Village, Colorado-based firm submitted to regulators. Aetna didn’t respond to interview requests.
Blue Cross and Blue Shield North Carolina, which declined to comment, referenced the No Surprises Act in letters sent to providers in March and November 2021, writing that it would end contracts with anesthesiologists, radiologists, emergency physicians and others unless they agreed to payment reductions of up to 30%.
UnitedHealth Group subsidiary UnitedHealthcare likewise requested a 40% decrease, according to a letter the American College of Emergency Physicians sent to the North Carolina congressional delegation in March.
North Carolina physicians charge some of the highest rates nationwide, with some out-of-network doctors billing at more than 1,000% of Medicare rates, a UnitedHealthcare spokesperson wrote in an email. “The No Surprises Act is bringing greater price transparency to the healthcare system and finally putting an end to the financially crippling surprise bills that consumers have struggled with for years,” the spokesperson wrote.
Doctors who accept these reimbursement cuts would struggle to keep their practices open and those who reject them would only be available out-of-network, said Ed Gaines, vice president of regulatory affairs and industry liaisons at revenue cycle management firm Zotec Partners. Both outcomes threaten patient access, he said. Health systems are already struggling with rising costs due to inflation, labor shortages and looming Medicare pay cuts, said Gaines, who sits on the American College of Emergency Physicians’ reimbursement committee.
“This is a reimbursement perfect storm like I have never seen in my 30 years,” Gaines said. At least three of his company’s emergency and anesthesiology clients have received similar notices from Cigna, he said.
To read more, go to Modern Healthcare.
|Coding Drives Up Medical Billing Costs in the US
By Jacqueline LaPointe | August 3, 2022
Complex coding structures in the US are driving up medical billing costs in the US, making it one of the most expensive countries to get paid, according to a new study.
The study published in Health Affairs used microlevel time-driven activity-based costing measurements to compare the billing and insurance-related (BIR) costs at provider offices in the US and five other countries.
The countries included single-payer systems (Canada), as well as multipayer systems in which there are public and private payers that reimburse providers (Germany and Australia). Researchers also included sites in Singapore, which uses a government subsidy model to reimburse providers global budget payments, and the Netherlands, which has universal and compulsory multi-private-payer coverage.
The study confirmed what research has established: BIR costs in the US are generally much higher than the costs in other countries. In fact, BIR costs ranged from a low of $6 in Canada to a high of $215 in the US for an inpatient surgical bill. In the US, that represented about 3.1 percent of the total professional revenue for the procedure. Providers also spent about 100 minutes processing the claim.
Only the sites in Australia had comparable BIR costs. The country has a mix of publicly and privately funded payers, as well as universal coverage. BIR costs were significantly less in Canada than in the other nations, while Germany, Singapore, and the Netherlands had comparable costs.
Higher costs in the US and Australia were attributed to higher coding costs, researchers found.
“We observed that high US costs are caused primarily by expensive and extensive coding activities, not higher wages paid to US personnel,” they wrote in the study.
Meanwhile, hospitals in Canada, Germany, Singapore, and the Netherlands had much lower coding-related costs. Researchers said the finding suggests that the US could achieve savings by “simplifying and standardizing payment procedures.”
The countries mentioned above may have vastly different ways of financing healthcare, but researchers noted a common thread with coding. Each country has national structures that standardize how payers reimburse providers. For example, providers in Canada, Germany, and the Netherlands have a standard list of charges, like Medicare’s diagnosis-related groups (DRGs). Contract terms for German and Dutch payers are also the same for most billing codes, with just a small fraction of billing code prices determined through negotiations between providers and payers.
The US has a very different coding process in which each payer has its own forms and documentation requirements, creating a significant burden on providers to translate clinical documentation into billable codes for reimbursement.
Because of standardization in other countries, providers spend less time coding or do not need coders to translate documentation into billable codes, researchers explained. Singapore also has an automated billing system to record and process its DRG codes based on ICD-10 codes and its list of charge codes.
To read more, go to RevCycle Intelligence.
|Where is Radiology with Pay-for-performance Now? 3 Expert Takes
By Dave Pearson | August 3, 2022
The value-based care era predates the passage of the Affordable Care Act in 2010, but that landmark event sufficiently reordered the rules of the game that modern pay-for-performance (P4P) watchers do well to start there.
Key subsequent developments included the Medicare Access and CHIP Reauthorization Act of 2015 (aka MACRA, aka the “permanent doc fix) and the P4P system it spawned, Medicare’s Merit-Based Incentive Payment System (MIPS, which went live on New Year’s Day 2017).
Ever since the latter date, diagnostic radiology has been one of the most challenged of all medical specialties to show its value via MIPS reasoning and reporting parameters.
A significant difficulty has been demonstrating imagers’ contributions apart from reading exams quickly and accurately. The whole “non-patient facing” thing enters the picture right about there—for both radiology groups and individual radiologists.
Fast-forward to the summer of ’22. The Journal of the American College of Radiology recently asked three experts on radiologist compensation for a written answer to a pressing question:
In creating the ideal practice-level P4P program, what elements must be considered, avoided and emphasized? JACR published the responses online August 1.
To read more, go to Radiology Business.
|Inpatient Hospitals get 4.3% Medicare Reimbursement Bump
By Maya Goldman | August 1, 2022
Medicare payments for hospital inpatient services will rise 4.3% in fiscal 2023 under a final rule the Centers for Medicare and Medicaid Services published Monday.
That amounts to (A)pay increase of about $2.6 billion and is higher than the 3.2% rate hike CMS proposed in April.
Hospital trade groups asked CMS to use its “exceptions and adjustments” authority to override the regulatory payment formula and give facilities anevenlargerincrease, but the agency declined to do so. The original proposed rate wouldn’t have adequately covered hospitals’ costs, industry groups said.
“Regarding commenters’ request that CMS consider other methods and data sources to calculate the final rule market basket update, we believe the 2018-based [inpatient prospective payment system] market basket continues to appropriately reflect IPPS cost structures and we believe the price proxies used…are an appropriate representation of price changes for the inputs used by hospitals in providing services,” CMS wrote in the final rule.
The rates for next fiscal year apply to general acute care hospitals that participate in the Hospital Inpatient Quality Reporting Program and use electronic health records, although other adjustments could impact individual hospitals’ rates, according to CMS. Long-term care hospitals will get a 2.3%, or $71 million, increase.
CMS used the most recent available data to set fiscal 2023 rates, despite the ongoing COVID-19 public health emergency. But the agency will continue to suppress and edit measures for its Hospital Readmissions Reduction Program, Hospital-Acquired Condition Reduction Program and Hospital Value-Based Purchasing Program to keep facilities from being rewarded or penalized by pandemic circumstances.
Medicare Disproportionate Share Hospital and Medicare uncompensated care payments will decrease by about $300 million in fiscal 2023, down from a proposed $800 million cut. CMS will distribute about $6.8 billion in uncompensated care payments next fiscal year.
To read more, go to Modern Healthcare.
|Why Do so Few Patients Utilize Online Access to Radiology Results?
By Hannah Murphy | August 1, 2022
Patients who utilize online patient portals often forego accessing their radiology results. New research examines the potential reasoning behind this.
The analysis included 424,422 patients, of whom 138,783 (32.7%) were enrolled in a single healthcare system’s patient portal. Out of the patients who were enrolled, just 27.1% utilized their access to radiology reports.
Junjian Huang, of the Department of Radiology at the University of Alabama at Birmingham, and co-authors sought to better understand what factors might prevent patients from fully utilizing online patient portals. They shared the details of their research recently in Current Problems in Diagnostic Radiology.
“There is a paucity of data specifically examining patient access to and use of radiology reports within the patient portal global environment,” the authors noted.
The team examined activity on the system’s patient portal over the span of 13 months to assess patients’ interactions with it. Specifically, they compared the use of the portal’s radiology tab (RADTAB), where imaging results could be accessed, to its laboratory tab (LABTAB), where patients found their lab results.
The analysis revealed that a significantly higher proportion of patients used the LABTAB (47.2%) compared to the RADTAB (27.1%). The researchers noted that demographic differences did not account for the difference in utilization.
To read more, go to Health Imaging.