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 1 st , 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

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 post anesthesia care area, and providing post anesthesia 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 $17.77 / $17.77

B = Medicare 2007 average anesthesia CF (est.) $16.23 / $16.23

C = Average units / case 12 / 12 D = Average # cases / year 900 / 900 E = Fraction of cases that are Medicare 0.35 / 1.00

X = CRNAs' Medicare practice economic value, 2006 $67,170.60 / $191,916.00

Y = CRNAs' Medicare practice economic value, 2007 $61,349.40 / $175,284.00

Z = Impact of Medicare cuts on above values $5,821.20 / $16,632.00

• • • X = A * C * D * E Y = B * C * D * E Z = X - Y

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

must leave a strong, positive impression with legislators CRNAs

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.