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May 2002
Volume 66 |
Number 5
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| Private Payer
Perils |
Alexander A. Hannenberg, M.D., Chair
Committee on Economics
Most of the practice economics issues discussed in these pages
pertain directly to the Medicare program. Not only is Medicare
the single largest health care payer in the nation, it has been
the subject of nearly all the economic advocacy efforts of ASA
and other medical specialty societies. The right to "lobby"
Medicare, as a government entity, is constitutionally protected
under the "redress of grievances" provisions of the
U.S. Constitution. The ability of physicians to form groups (such
as ASA) for the purpose of advocacy in the private sector is much
more restricted because of antitrust limitations applicable to
individuals without a contractual or financial relationship.
Despite these limitations, professional societies have a duty
to inform their members of significant events in the private payer
arena and to provide guidance to payers seeking recommendations
or advice from the specialty. When unreasonable policies are promulgated
we should communicate the concerns of the membership to the payers.
Several recent examples of such activities form the basis of this
article.
A number of private insurance carriers have recently introduced
requirements for anesthesiologists to use the series of modifiers
established by Medicare to facilitate a variety of Medicare-specific
anesthesia payment policies. These modifiers in table 1 are a
part of Medicare claims processing, not the Current Procedural
Terminology (CPT™) coding system. The claims standardization
provisions of the Health Insurance Portability and Accountability
Act require neither the use of the Medicare modifiers nor Medicare
payment policy.
Medicare pays physicians 100 percent of its fee schedule amount
for anesthesia services personally provided by an anesthesiologist
and for services of an anesthesiologist medically directing a
single resident. Medicare pays the physician 50 percent of the
fee schedule amount for medical direction of "qualified individuals"
(i.e., nurse anesthetists/anesthesiologist assistants/residents).
In the case of medical direction of nurse anesthetists or anesthesiologist
assistants, an additional 50 percent payment is made for the services
of the "qualified individual," but Medicare makes no
such payment for resident services when more than one resident
is directed concurrently. Thus, teaching physicians involved with
more than one concurrent procedure will see only 50 percent of
the fee schedule amount for those cases involving residents. The
stated basis for this policy is Medicare's well-established funding
mechanism for graduate medical education (GME), though it is often
pointed out that no such reduction is imposed for other specialists
involved with more than one trainee concurrently. Medicare would
argue that separate payment for the resident service would duplicate
its payments through GME.
Medicare requires that all claims for monitored anesthesia care
(MAC) be identified with a QS modifier. A number of Medicare carriers
have imposed a variety of arcane medical necessity policies on
MAC services, but payment for these services – when compliant
with local policies – is identical to those for all other
anesthetics. Medicare does not routinely require any special documentation
for MAC.
In a memorandum to providers this fall, Aetna U.S. Healthcare
announced that it will require use of Medicare modifiers in submitting
claims for anesthesia services beginning April 1, 2002. This new
policy document stated that claims with a QS modifier for MAC
services provided to ASA physical status 1 or 2 patients in the
outpatient setting would not be allowed. ASA immediately contacted
the medical leadership at Aetna to point out the magnitude of
the impact this unique policy would have on clinical care. In
a series of conversations, we stressed that most outpatient surgeries
performed with MAC could not be accomplished without any anesthetic
service and that general anesthesia was often a less appropriate
choice. We emphasized that a global payment prohibition of this
nature was an inappropriate mechanism to address whatever medical
necessity concerns the payer might harbor about MAC. Happily,
James Cross, M.D., and Jeffrey Livovich, M.D., at Aetna recognized
the flaws in the policy and responded to ASA's request with an
announcement that the policy on MAC was rescinded. In this instance,
the payer was both accessible and responsive, and an ill-conceived
assault on quality care was averted.
Aetna also had imposed a policy of reducing payments for monitoring
procedures performed in conjunction with anesthesia services (or
for multiple monitoring procedures on the same day) by 50 percent.
These "multiple procedure payment reductions" are typically
applied to multiple surgical procedures performed at the same
session, but CPT standards explicitly exclude the common monitoring
procedures from these payment reduction rules. We were able to
point out to Aetna that its payment policy in this area was inappropriate
and inconsistent with industry standards. As with the MAC policy,
Aetna's leadership responded to ASA's requests with a revocation
of this payment policy.
United Healthcare, a private payer doing business in 43 states,
is also among the private payers with a requirement for the use
of Medicare modifiers. Notably, United Healthcare, like virtually
all private health insurers, has no role in funding graduate medical
education, yet has introduced a payment policy for teaching anesthesiologists
that mimics Medicare's. The introduction of this payment policy
(in the absence of new funding for GME from United) produces a
50-percent fee cut for teaching anesthesiologists and their institutions.
ASA has contacted the medical leadership at United Healthcare
to express its concerns about this policy but has had no indication
that the health plan will alter it. Naturally, ASA cannot negotiate
any exemptions from these policies, but individual providers and
practices are legally permitted to seek remedies for themselves.
Members of the Committee on Economics and the ASA Washington
Office are eager to represent the concerns of members to payers,
both public and private, and to alert members to economic issues
that affect their practices. As these examples illustrate, our
advocacy occasionally produces gratifying results, but even when
ASA is unable to achieve a global solution, we can equip our members
with the knowledge necessary to formulate their individual responses
to important contracting issues.
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Alexander
A. Hannenberg, M.D., is Associate Chair, Department of Anesthesiology,
Newton Wellesley Hospital, Newton, Massachusetts. |
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