he ASA Committee on Economics (COE) strives for enhanced benefit for our members by seeking fair payment with minimal hassles from all payers, both public and private. The role of COE has evolved with the maturation of the medical market. The history of COE’s interactions with private insurers is linked to the evolution of government payment methods and policies, most notably the resource-based relative value scale (RBRVS) and the Medicare payment rules, both national and carrier-specific. Discussions with insurers can be initiated by either the insurer or COE on behalf of membership. The discussions are generally a matter of policy or process. The majority of the interactions of COE with private insurers are questions of payment policy. Questions also arise in the specifics of the payment process. Primarily through the efforts of the ASA Washington Office and ASA’s Coding and Reimbursement Manager Sharon Merrick, CCS-P, COE has often educated insurers, practice managers, professional coders and physicians in issues concerning correct coding, modifiers, crosswalk and time. These initiatives usually start with an ASA member’s request for help. In reviewing the history of COE with public and private payers, a number of recurrent issues are illustrated to remind us that the more things change, the more they stay the same.

In the 1970s, the U.S. Department of Justice sued ASA, claiming that publication of the Relative Value Guide™ (RVG) resulted in illegal price-fixing. Despite ASA’s successful resolution of this lawsuit, the experience created great concern about ASA’s antitrust exposure for both leadership and staff and has colored ASA’s relations with payers since that time. As a result, there was little exchange of information between private insurers and ASA and COE for many years.

Under the leadership of Steven “Butch” Thomas, M.D. (chair, 1988-1996), COE focused on the development of RBRVS and the retention of separate anesthesia time as the predominant payment issues facing ASA. To paraphrase Dr. Thomas, “private insurers were not the Monoliths they are today, and the main issues were coding.” Early discussions with Medicare took place at this time concerning the medical necessity of monitored anesthesia care (MAC) services. Some initial contacts with the private sector occurred with individual Blue Cross/Blue Shield entities concerning issues of obstetric billing. These questions of best methods for obstetric billing ultimately led to the development of the current obstetric billing options found in the RVG. An additional issue embraced by COE under Dr. Thomas was an attempt to have the ASA House of Delegates (HOD) adopt a policy to endorse the separate payment for postoperative pain services by the same anesthesiologist providing operative anesthesia services.

During the tenure of L. Charles Novak, M.D., as COE chair (1997-2000), the antitrust concerns continued to dominate COE’s interactions with private insurers; however, at that time, Dr. Novak initiated discussions with a medical director from a major insurer. This initial relationship has developed into one of mutual respect with the exchange of information valuable to both parties and, by extension, to ASA’s membership. While the early antitrust concerns persist and consideration of fees remains off the table, the dialogue with private insurers has matured to allow constructive discussions in many areas.

Questions often arise during the development of carrier payment polices. Private payers develop payment policies as an internal process, while the external target of these policies are providers. The level of provider input to private insurer payment policy is highly variable and depends upon the insurer making a request for comment or information. An early example of ASA playing a role in payment policy development occurred during the tenure of Alexander A. Hannenberg, M.D., COE chair from 2001-03, and concerned a question of medical necessity for MAC. Specifically, ASA/COE received a request for a comment on the use of separate anesthesiology services for sedation during trigger-point injections.

COE serves as the clearinghouse for questions of payment policy for ASA. Current examples of payment policy challenges earning COE attention include anesthesia services for GI endoscopy, postoperative pain procedures and fluoroscopic guidance for spinal injections. Where official ASA policy as codified by HOD action is available, this is utilized as the primary resource. COE has asked for approval of position statements on payment for postoperative pain procedures and fluoroscopic guidance for spinal injections at the ASA 2007 Annual Meeting in San Francisco. Other formal ASA policies initiated by past COE recommendation include statements opposing bundling of payments for invasive monitoring procedures and transesophageal echocardiography into payments for anesthesia service as well as statements defining MAC and differentiating MAC from sedation services.

The delicate nature of discussions with private insurers is appreciated at all levels of ASA/COE. Individual members of COE, by virtue of expertise in coding and billing in a specific area of anesthesia services, may offer opinions and interpretations when requested. These are accompanied by a disclaimer that these opinions are not necessarily those of ASA, except for those specifically repeating ASA HOD-approved statements. These individual discussions often provide information about insurer payment policy that may be applicable to a broader cross-section of the membership.

Private insurer payment policy has tracked the evolution of government payment rules since insurers can more easily hide behind the government’s actions compared to home-grown initiatives. The recent wave of mergers and acquisitions has consolidated private insurers into fewer, but much larger, companies that increasingly adopt government payment policies advantageous to their business interests. This is evidenced by the broad adoption of RBRVS and the private insurer implementation of Medicare-like teaching payment reductions in some markets. The resources dedicated to governmental payment policies have had great impact on the private insurer market, and the development of private and public payment policies has reflected maturation in the general health care market. Future challenges in payment policy will include implementation of pay-for-performance programs and focusing increased attention on medical necessity for anesthesia services, including those supporting GI endoscopy.

The opportunity for education, exchange of information and playing a role in the development of payment policies has predicated the interaction of COE with private insurers. What you do not know, you cannot influence.

Randall P. Maydew, M.D., M.B.A., is in private practice at Medical City Dallas Hospital, Presbyterian Dallas Hospital, Baylor University Medical Center, and Baylor Regional Medical Center of Plano, Dallas, Texas.

Norman A. Cohen, M.D., is Assistant Professor, Department of Anesthesiology and Peri-Operative Medicine, Oregon Health & Science University, Portland, Oregon.