Transcript Identify the issue/problem.

Medicare Reimbursement
Professional Aspects
MSNA 699
SRNA Project Summer 2007
Brian Brister
Gary Boutwell
Errica McGregor
Janet Pilkington
D.J. Rawlinson
Brian Watson
The issue / The problem
Medicare Reimbursement and
its impact on CRNA practice
Brief Description and History
• Medicare was established in 1965 with the
enactment of Medicare and Medicaid legislation.
• Originated as a health insurance program for the
elderly paid for by Social Security Taxes.
• Initially only provided insurance services for
physician's and hospitalization. Now provides
reimbursement for other healthcare providers to
include CRNA’s.
History (cont.)
• 1976: AANA sought to receive direct
reimbursement from Medicare.
• 1983: Prospective Payment System was devised
to contain hospital cost and allowed many
outpatient procedures to be reimbursed.
History (Cont)
• The Omnibus Reconciliation Act of 1987 required
Medicare to implement a separate payment within the
professional services sector for CRNA reimbursement.
– Went into effect January 1st, 1989.
• Prior to 1989, anesthesia reimbursement was limited to the
services provided by a physician.
–
•
Medicare B, is the division responsible for CRNA
reimbursement.
Prior to this act, CRNA’s were reimbursed by Medicare
Part A, which is the division responsible for hospital or
institutional reimbursements.
Divisions of Medicare
• Medicare Part A
- Payment for hospitals and ambulatory care
facilities under Medicare.
- Requires CRNA’s to work under the direct
supervision of MDA’s as a condition for
reimbursement from Medicare.
Divisions of Medicare
• Medicare Part B
- CRNA reimbursement.
- Payment for Medical direction and Medical
supervision. ( Seven conditions of TEFRA must
be met).
CRNA Medicare Billing
Requirements
Only a Certified nurse anesthetist can bill
Medicare directly. (140.1.2 of the Medicare
Claims Manual)
What does Medicare require to bill for
services?
1. Certification
2. Recertification - Req. by AANA, assumed
complete by CMS
3. NPI (National Provider Identifier)
Reimbursement
• “ Today, reimbursement for CRNA services is many
times ignored, overlooked, or assumed, all of which
can result in a negative economic impact upon
CRNAs within the healthcare marketplace. Today’s
healthcare spending is highly scrutinized; therefore,
no reimbursement opportunities can be left
untapped, including those present in the system for
the services of CRNA’s. The future of the profession
relies on the ability of CRNAs to accurately
understand the healthcare marketplace. CRNAs
must be able to identify their worth, understand the
reimbursement process, and assist their employer
or secure for themselves through private practice
the proper portion of today’s healthcare dollar that
is due for the services they provide.” (1)
Medicare FACTS
• CRNAs first nonphysician provider to be directly
reimbursed by Medicare Part B
• Approx. 27 million anesthetics are provided by
CRNAs in the U.S. annually
• Medicare reimburses anesthesia $2.4bn / yr
• – $1.7bn for anesthesiology
• – $657mn for nurse anesthesia
• – Up 25% from 2005 level of $1.9bn
CMS, 2007 PFS final rule [CMS-1321-FC & CMS-1317-F], 11/1/2006
Issue related to the practice
standards / guidelines
Medicare uses the TEFRA conditions simply to
determine if an anesthesiologist has been
adequately involved in the administration of an
anesthetic to justify paying the anesthesiologist.
Issue related to the practice
standards / guidelines (cont.)
• Medicare has no requirement of anesthesiologist
supervision and will reimburse CRNAs who are
not supervised by any physician if they meet the
appropriate requirements.
• Due to the seven conditions of TEFRA, five
Standards of Practice for the nurse anesthetist
apply to Medicare reimbursement.
1. Preanesthetic evaluation of the
patient
• Performing and documenting a pre-anesthetic
assessment and evaluation of the patient,
including requesting consultations and
diagnostic studies
• Selecting, obtaining, ordering, or administering
pre-anesthetic medications and fluids
• Obtaining informed consent for anesthesia
2. Prescription of the anesthesia plan
• Developing and implementing an anesthetic plan
3. Personal participation in the most
demanding procedures in this plan, especially
those of induction and emergence
• Developing and implementing an anesthetic plan
• Selecting and initiating the planned anesthetic technique
which may include: general, regional, and local
anesthesia and intravenous sedation
• Managing emergence and recovery from anesthesia by
selecting, obtaining, ordering, or administering
medications, fluids, or ventilatory support in order to
maintain homeostasis, to provide relief from pain and
anesthesia side effects, or to prevent or manage
complications.
4. Following the course of anesthesia
administration at frequent intervals
• Selecting, obtaining, or administering the
anesthetics, adjuvant drugs, accessory drugs, and
fluids necessary to manage the anesthetic, to
maintain the patient's physiologic homeostasis,
and to correct abnormal responses to the
anesthesia or surgery
5.
Ensure all procedures not personally
performed are performed by a qualified individual
The Standard of Practice that matches that would be:
• All eleven Standards apply - because the CRNA is
performing the anesthesia
6. Remain physically available for the immediate
diagnosis and treatment of emergencies
• Responding to emergency situations by providing
airway management, administration of emergency
fluids or drugs, or using basic or advanced cardiac
life support techniques
• Selecting, obtaining, or administering the
anesthetics, adjuvant drugs, accessory drugs, and
fluids necessary to manage the anesthetic, to
maintain the patient's physiologic homeostasis, and
to correct abnormal responses to the anesthesia or
surgery
7. Providing indicated postanesthesia care
• Releasing or discharging patients from a postanesthesia care area, and providing postanesthesia follow-up evaluation and care related
to anesthesia side effects or complications
Plan of Action
“As long as there is government there will
always be a need for a plan of action.”
-
Gary Boutwell
July 11,2007
Increase funding for education
• In 2006 the educational fund was $3 million.
• In 2008 our plan is to increase nurse anesthesia
educational funding to $4 million which will
provide more nurse anesthesia educational
programs and increase grants which will
support existing programs by escalating
enrollment.
• Supporting more graduates to practice in
medically underserved areas.
Change Teaching Rules!
• It is fundamental that Medicare treat nurse
anesthetists and anesthesiologists the same
to insure educational equal opportunity
• Equality in teaching anesthesiologists, nurse
anesthetists, residents and student
anesthetists.
• Medicare cuts in pay = discouragement in
providing educational services.
How Does This Funding Help?
• Grants help establish, strengthen CRNA
educational programs
• Traineeships provide some funding for second-year
students
• 105 Accredited Nurse Anesthesia programs
• Total CRNA educational funding -- $3-4million/yr
• Over 2,000 graduates in 2006, more than doubled
since 2000
Past Actions
• Take Action - It has been proven effective in
the past.
• HR 3617
• S 1356
• HR 6111
• Results: CRNA’s are treated as equal healthcare
providers.
Medicare Agency Final rule provisions
of interest to CRNAs
Finalizes 13.7% Cut in 2007 Part B Anesthesia Payment; No
Change in Anesthesia Teaching Rules
• There is no change in the Medicare anesthesia payment teaching rules
in the final rule
– Legislation introduced in Congress, the "Medicare Academic
Anesthesiology and CRNA Payment Improvement Act" (HR 6184), would
fix problems in the Medicare anesthesia payment teaching rules for both
CRNAs and anesthesiologists. This legislation is supported by AANA.
• CMS is applying changes in evaluation and management (E/M) code
values to those anesthesia services where E/M constitutes a portion of
the service
– CMS proposed in its proposed rule to modestly increase the anesthesia work
value to reflect the increased work valued for the E/M codes where there were
increases in the work for those E/M codes.
Medicare Agency Final rule provisions
of interest to CRNAs (cont.)
• CMS included two new CPT codes for anesthesia
– The codes, 00625 and 00626 (anesthesia spine
transthoracic with and without ventilator, respectively)
would have base units set to 13 for 2007. CMS accepted
AMA Relative Value Update Committee (AMA RUC)
recommendations for these codes.
• CMS made value changes to other CPT codes
outside anesthesia services
– such as for certain surgical services, which may impact
demand for certain anesthesia services.
Act Now!
• Thanks to action in 2006 (HR 6111); 5% of
approximately 14% planned Medicare cuts for
2007 was reversed.
• This relief is only temporary (last for 1 year).
• Without congress’ action and HR6111 the 2007
anesthesia conversion factor would have
decreased from $17.76 (2006) to $15.33 not
experienced since before 1992.
• Without further action cuts will resume in 2008
and so on, could be as much as 40% by 2012.
• We need a long term solution; CMS – will
continue to assess and call for budget
adjustments.
Get involved!
• Maintain AANA active membership –
• Support the AANA monetarily –
• Communicate with Congress about these extreme cuts,
using AANA online eAdvocacy, www.aana.com
• Remember to note effects on patients’ access to
healthcare services –
• Meetings with legislators in local communities• Recruit CRNAs to support AANA –
• Get to know the AANA, stay informed, stay in touch
with AANA DC –
• Get to know your legislatures- they can influence every
aspect of your job, particularly your paycheck.
Why is it important?
• How will anesthesia professionals, anesthesia
groups, hospitals and offices deal with cuts in
anesthesia reimbursement per-service?
• Answer?
• Two fundamental choices: increase revenues, or
decrease costs.
• Majority of CRNAs assign their billing rights to an
employing group, hospital, or facility
• CRNAs’ should learn and know their own
economic value in the practice setting – the
revenues a CRNA’s work produces.
Do you know your worth?
• Medicare Anesthesia Economic Value Calculator
U.S. Averages 100% Medicare /Sample Personal Figures
A = Medicare 2006 average anesthesia CF
B = Medicare 2007 average anesthesia CF (est.)
$17.77 /
$16.23 / $16.23
C = Average units / case
12 / 12
D = Average # cases / year
E = Fraction of cases that are Medicare
X = CRNAs' Medicare practice economic value, 2006
Y = CRNAs' Medicare practice economic value, 2007
Z = Impact of Medicare cuts on above values
•
•
•
X=A*C*D*E
Y=B*C*D*E
Z=X-Y
$17.77
900 / 900
0.35 / 1.00
$67,170.60
$61,349.40
/ $191,916.00
/ $175,284.00
$5,821.20
/ $16,632.00
How to ACT?
• Through AANA: guide legislators to introduce
appropriate bill.
• In our case a bill reversing Medicare cuts.
• CRNA’s act by writing there appropriate
members of congress, to pass said bill.
• State associations and others write letters of
support.
ASA’s actions
• “Teaching Rules” - which effect reimbursement
of students providing anesthesia (nurse
anesthesia students and residents in anesthesia).
• Introducing bills specific to anesthesiologist and
residents.
• HR 5246
• HR 5348 Stark
• S2990 Vitter
• These bills have not been adopted
Resources
•
•
•
•
•
Meetings – local, state, and federal.
AANA – website: www.aana.com
AANA News Bulletin
CMS website
Alabama Association of Nurse Anesthetist www.ala-crna.org
• Realize AANA has a DC office.
Proposed alternative and
timetable for resolution
Issues for Lobbying Capitol Hill
• Educating Legislators About CRNAs
• Keeping Medicare Strong
• Equity in CMS Anesthesia Teaching Rules
• Nurse Anesthesia Education Funding
Get involved NOW !!
• Attend the 2007 AANA midyear assembly in
Denver, CO.
• Let your voice be heard!!
• As Washington looks for answers to healthcare
financing, access and quality issues CRNAs
must leave a strong, positive impression
with legislators for our issues & the others to
come.
Current status of Medicare problem
• The Washington Environment
In Government:
– New Democratic Congress
– Jockeying to succeed President Bush
In Policy:
– Budget running enormous deficits,
short- and long-term
Focus: War, healthcare, budgets
Current status of Medicare problem
• The Washington Environment
In healthcare:
the public’s second-highest issue interest
– Fiscal challenges – Part B cuts
– Pay-for-performance / quality
reporting / health I.T.
Insurance reforms:
Singlepayor, employer mandate,
tax incentives
Obstacles to big initiatives
Who Matters in Government?
• The people who make the rules
• The people who enforce the rules
• The people who pay for things
Why Do They Matter to CRNAs?
• Congress’ Committees of Jurisdiction
– Medicare-writing: House Ways & Means,
Senate Finance, House Energy & Commerce
– Funding: House and Senate Appropriations
– Education & Other Health: House Energy &
Commerce, Senate Health Education Labor &
Pensions
CRNAs Make A Difference
• •CRNAs are ensuring clinical excellence
– Accreditation, cert, recert, practice standards
• CRNAs develop expertise in policy areas
– Meetings, training, committees, advisory panels
• We have gotten organized
– AANA, CRNA-PAC
• • We are applying what we know in Washinton D.C.
Today!
Medicare Payment Trends
•
•
•
•
•
•
2004 :
2005 :
2006 :
2007 :
2008 :
2009-2012:
+1.5%
+1.5%
No change
8% (not -14% as originally proposed)
- 10%
- 25-30%
Medicare Payment Trends
• Cuts will come unless Congress acts
• Medicare payment drives other payments
– Government programs like Medicaid
– Federal employee benefits (FEHBP,
TRICARE/Champus)
• Unlike in 2007, all Part B providers are in
the same boat
CRNA Education Message
Congress should request:
• $4 million for Nurse Anesthesia Education
• $76 million for advanced education nursing
• •$200 million in total for nurse education
The BIG Message
• Medicare anesthesia payment got cut in 2007
• Future Medicare payment cuts of up to 35-40%
in five years would destroy the Medicare
program for our seniors
• Congress should enact legislation to reverse
Medicare Part B physician fee schedule cuts
that are scheduled for 2008 and beyond.
• Continue to include CRNAs in the development
of pay-for-performance quality measures
You Make the Difference!
For Our Patients, Practice and Profession
Your DC Office:
• Frank Purcell, Sr Dir, Federal
Govt Affairs
• Brian R. Bullard, Assoc Dir,
Federal Govt Affairs
• Pamela Kirby, Assoc Dir, Federal
Regulatory & Payment Policy
• Shari Dexter, Political Affairs Mgr
• Candi Richardson, Senior
Administrative Assistant
Questions
1. What act required Medicare to implement a separate payment
within the professional services sector for CRNA
reimbursement? What year did it go into affect?
2. What part of Medicare is the division responsible for CRNA
reimbursement?
3. True/False The 7 conditions of TEFRA apply to CRNA
reimbursement and directly correlate with most of the CRNA
Scope of Practice.
• True/False In order for the CRNA to be reimbursed by
Medicare, he must be supervised by a physician.
Questions
4. What governmental group/committee is
established for approving or denying federal
program funding?
5. Why does the educational fund for nurse
anesthesia need to be increased from 3 million to
4 million?
6. How will anesthesia professionals, anesthesia
groups, hospitals, and offices deal with cuts in
anesthesia reimbursement per-service?
References
1. Foster SD, Faut-Callahan M. A professional Study and Resource
Guide for the CRNA. Park Ridge, IL: AANA Publishing Inc;
2001 : 180-181, 288, 358.
2. Culpepper TL. History of Nurse Anesthesia, PowerPoint /
Lecture. Samford University, Ida V. Moffett School of
Nursing, Department of Nurse Anesthesia; June 12, 2007:
pg.4, slide 3.
3. Nagelhout JJ, Zaglaniczny KL. Nurse Anesthesia. 3rd ed.
Philadelphia, PA; Saunders; 2005: 1249-1263.
4. AANA Professional Manual for CRNAs (www.aana.com)
References
5. Scope and Standards for Nurse Anesthesia Practice. Park
Ridge, III: American Association of Nurse
Anesthetists; 1996.
6. American Association of Nurse Anesthetists - Office of Federal
Government Affairs. www.aana.com. Apr. 2007.
7. American Association of Nurse Anesthetists - Office of Federal
Government Affairs. www.aana.com. Mar. 2007.
8. Blumenreich GA. Standards of Care and the ASA Medical
Direction Statement. AANA Journal, Vol. 72 (No. 2);
2004.
References
9.
Purcell, FJ. Government Relationship and Federal Issues. AANA
Mid-year Assembly PowerPoint Presentation. May-June 2007.
www.aana.com. Accessed and permission granted July 20, 2007.
10.
Purcell, FJ. Analysis of Federal Issues. AANA Mid-year
Assembly PowerPoint Presentation. May-June 2007.
www.aana.com. Accessed and permission granted July 20, 2007.
11.
Purcell, FJ. CRNAdvocacy 101: How CRNAs’ Action Affects
CRNAs’ Patients, Practice & Profession. AANA Mid-year Assembly
PowerPoint Presentation. May-June 2007. www.aana.com.
Accessed and permission granted July 20, 2007.