Medicare Payment Federal Statutes Governing Reimbursement of CRNA Services

Transcription

1 ertified Registered Nurse Anesthetists (CRNAs) are reimbursed through various government programs and public and private plans for the high-quality anesthesia care and related services they provide to patients. This paper is intended to shed light on this complex topic. Medicare Payment By far the largest health plan in the United States is the Medicare program for senior citizens and certain individuals with disabilities. The Medicare Part B program reimburses CRNAs directly for anesthesia services provided to Medicare beneficiaries, and for certain medical and surgical services specified in Medicare payment policy. Medicare Part B pays for CRNA services by a formula, the sum of base units (which characterize the complexity and difficulty of an anesthesia case) and time units (15 minutes equals one unit) multiplied by a dollar-value anesthesia conversion factor (anesthesia CF). Most health plans, public and private, reimburse for CRNA services using this same formula, varying the anesthesia CF to yield a fee for each service. In qualifying rural hospitals, Medicare Part A reimburses the hospital for the reasonable cost of nurse anesthetist services to Medicare patients, within certain parameters. Medicare reimbursement for CRNA services is determined by acts of Congress, interpreted and implemented through Medicare regulations subject to notice and comment, and further carried out through Medicare payment policy described in Medicare payment manuals. Federal Statutes Governing Reimbursement of CRNA Services Following is a list of federal statutes governing the reimbursement of CRNAs, from the inception of Medicare to the present. Enacted in 1965, Medicare (Title XVIII of the Social Security Act) reimbursed hospitals under Part A for reasonable costs of anesthesia services provided by hospital-employed CRNAs. Anesthesiologists who employed and supervised CRNAs could bill under Part B as if they personally performed the case; anesthesiologists who supervised CRNAs who were employed by a hospital could bill the same base units as if they did the case themselves, but their time units were halved. The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) established conditions that anesthesiologists must fulfill in order to be paid for medically directing anesthesia services provided by CRNAs. In addition, TEFRA limited to four the number of concurrent cases anesthesiologists could medically direct to gain reimbursement. From this statute and subsequent regulations developed and issued by the Medicare agency evolved the rules known as the TEFRA rules, or medical direction rules. For Medicare Part B to pay an anesthesiologist a claim for providing medical direction services, the anesthesiologist must attest that he or she completed the following in each case: (1) performed a pre-anesthetic examination and evaluation; (2) prescribed the anesthesia plan; (3) personally participated in the most demanding procedures in the anesthesia plan, including induction and emergence; (4) ensured that any procedures in the anesthesia plan that he or she did not perform were performed by a qualified anesthetist; (5) monitored the course of anesthesia administration at frequent intervals; (6) remained physically present and available for immediate diagnosis and treatment of emergencies; and (7) provided indicated post-anesthesia care. Anesthesiologist medical direction of CRNA services is not required by the Medicare program; rather, medical direction is defined by Medicare Part B as a system for payment when Over

2 the medically directing anesthesiologist meets the seven requirements specified above for anesthesia care otherwise furnished by a CRNA. The Social Security Amendments of 1983 created the Prospective Payment System (PPS). Under the PPS, all hospital Part A payments were bundled into diagnosis-related groupings (DRGs). Establishment of the DRG system presented anesthesia payment problems. Hospitals would have been required to pay for their CRNA employees from the fixed DRG payment, jeopardizing their ability to recoup actual costs and creating a disincentive for hospitals to employ CRNAs. In addition, the PPS precluded the unbundling of services, and anesthesiologists who employed CRNAs would have been forced to contract with hospitals to claim the CRNA portion of the DRG. The problems were subsequently resolved, and medicare anesthesia payment is now made predominantly through Part B. The Deficit Reduction Act of 1984 established a pass-through provision for the costs of hospitalemployed CRNAs for a three-year period, assuring hospitals that they would not lose money by employing CRNAs. It also allowed an exception to the unbundling provisions in the PPS to accommodate anesthesiologists billing for their CRNA employees. However, due to the temporary nature of the pass-through provision, the American Association of Nurse Anesthetists (AANA) sought and secured a legislative remedy that would provide for direct reimbursement of CRNA services through Medicare Part B. The Omnibus Budget Reconciliation Act of 1986 established direct reimbursement for CRNAs under Medicare Part B, effective January 1, It also continued the previously existing forms of hospital and anesthesiologist billing for CRNA services under Medicare until December 31, The Omnibus Budget Reconciliation Act of 1987 imposed reductions in base units for anesthesiologists who medically direct CRNAs. Anesthesiologists base units were reduced by 10 percent when medically directing CRNAs in two concurrent procedures, 25 percent for three procedures, and 40 percent for four procedures. The Medicare agency, then known as the Health Care Financing Administration (HCFA), also adopted the 1988 American Society of Anesthesiologists (ASA) Relative Value Guide (RVG) as its Uniform RVG for services provided on or after March 1, The Omnibus Budget Reconciliation Act of 1989 created the Resource-Based Relative Value Scale (RBRVS) system for determining the relative value of services delivered by CRNAs, anesthesiologists, physicians, and other Medicare Part B providers. During this time, anesthesiologist services were found to be overvalued, resulting in decreased conversion factors beginning in The Omnibus Budget Reconciliation Act of 1990 statutorily established higher Medicare conversion factors for CRNAs effective January 1, The nonmedically directed CRNA conversion factors would begin in 1991 at $15.50 per unit, rising to $16.75 per unit by The medically directed CRNA conversion factors were set at 70 percent of the nonmedically directed CRNA rate. Therefore, the medically directed CRNA conversion factors would begin in 1991 at $10.50 and eventually reach $11.70 by However, nonmedically directed CRNA conversion factors could not exceed the anesthesiologist conversion factors in the same carrier locality. The Omnibus Budget Reconciliation Act of 1993 included cuts in payment for services when a CRNA is medically directed by an anesthesiologist. It was determined that the cost of the medically directed anesthesia services model was as much as 140 percent of the cost of a solo provider. Consequently, beginning January 1, 1994, the payment for the anesthesia care team was Next Page

3 Reimbursement of CRNA Services (Continued) capped at 120 percent of what a solo anesthesiologist would be paid, split 50/50 between the CRNA and the anesthesiologist. The cap was then reduced an additional 5 percent each year over a four-year period, ending in 1998 with a permanent 100 percent cap split 50/50 between the CRNA and anesthesiologist. The law also repealed the 10 percent, 25 percent, and 40 percent reductions in base units when an anesthesiologist would medically direct two, three, and four CRNAs respectively, and repealed the use of 30-minute time units in medical direction cases. Anesthesiologists could still be paid for medically directing CRNAs in up to four cases. Most recently, the Medicare Improvements for Patients and Providers Act of 2009 (MIPPA) included provisions affecting Medicare Part B reimbursement of anesthesia services when education of students is involved. With respect to CRNAs, the provision allows for a teaching CRNA to be reimbursed 100 percent of a Medicare fee in each of up to two concurrent cases in which a student nurse anesthetist is involved. Implementation of the provision is subject to a final rule published in the Federal Register in November 2009, and is in effect for services delivered January 1, 2010, and thereafter. Common Reimbursement Modalities Medicare Part B and most public and private health plans reimburse for CRNA services through four common modalities: (1) nonmedically directed CRNA services, (2) medically directed CRNA services, (3) medically supervised CRNA services, and (4) reasonable cost pass-through payments for CRNA services under Medicare Part A for qualifying rural hospitals or critical access hospitals (CAHs). Medicare and most public and private plans also reimburse CRNAs for the provision of certain medical and surgical services, such as line insertions and interventional pain management services, under the ordinary physician fee schedule so long as the service is within the CRNA s scope of practice in the state where the service is provided. Nonmedically directed CRNA services are reimbursed by Medicare Part B at 100 percent of a Medicare fee through the anesthesia fee schedule. This payment is appropriate when a CRNA provides the entire anesthesia service, or when an anesthesiologist is involved in a case but not to a degree sufficient to warrant a claim for anesthesiologist medical direction. Medically directed CRNA services are reimbursed by Medicare Part B at 100 percent of a Medicare fee through the anesthesia fee schedule, with the CRNA being paid 50 percent of the fee and the medically directing anesthesiologist being paid the remaining 50 percent of the fee. While the medically directing anesthesiologist may claim to have provided the service of medical direction for up to four simultaneous cases, Medicare requires the anesthesiologist to attest that he or she met the seven requirements specified in the TEFRA rules in each and every case for which the claim is made. Medically supervised CRNA services are reimbursed by Medicare Part B at more than 50 percent, but less than 100 percent, of a Medicare fee through the anesthesia fee schedule. The medically supervised CRNA is reimbursed 50 percent of the Medicare fee, while the medically supervising anesthesiologist is reimbursed two or three base units for each case in which the anesthesiologist is involved. The medically supervising anesthesiologist may claim reimbursement for medical supervision in five or more concurrent CRNA cases, or in fewer than five CRNA cases where the anesthesiologist has been involved in the cases but has not met all of the TEFRA requirements to be able to claim anesthesiologist medical direction. Because medically supervised CRNA services characteristically yield less than 100 percent of an anesthesia fee under Medicare Part B, most practices either avoid this practice Over

4 modality or choose instead to submit claims as nonmedically directed CRNA services which are reimbursed at 100 percent of a fee under Medicare Part B. For certain qualifying rural hospitals or CAHs where the volume of cases requiring anesthesia services is relatively light for a hospital, Medicare Part A offers a program for reasonable cost pass-through payments for CRNA services. Under this program, a qualifying hospital may be paid on a reasonable cost basis for one full-time CRNA providing 800 or fewer inpatient and outpatient anesthesia procedures. Where the hospital qualifies for and receives such pass-through funding from the Medicare program, neither the hospital nor the CRNA providing services at that hospital may bill Medicare Part B for anesthesia services provided to Medicare beneficiaries at that hospital. Finally, Medicare Part B and most public and private plans reimburse for certain medical and surgical services provided by CRNAs that are not anesthesia services, so long as the CRNA is authorized to furnish those services in the state where the services are being provided. The Medicare claims processing manual identifies these services as insertion of Swan Ganz catheters and central venous pressure lines, pain management, emergency intubation, and the preanesthetic examination and evaluation of a patient who does not undergo surgery. These services are reimbursed under the regular Medicare physician fee schedule, not the anesthesia fee schedule. Further, because the concept of anesthesiologist medical direction applies only to anesthesia services and not to medical and surgical services, when a CRNA provides these medical or surgical services Medicare reimburses 100 percent of the fee to the CRNA and anesthesiologist medical direction payment does not apply. Public and Private Health Plans The services of CRNAs are reimbursed directly by most public and private health plans. Medicaid program benefits and reimbursements vary state by state, but at least 38 state Medicaid programs responding to a 2008 survey indicated that they reimburse CRNAs directly for their services. The remaining 12 states either did not respond to the survey, or responded one of two ways: They reimburse facilities (but not CRNAs directly) for CRNA services, or they reimburse for medically directed CRNA services. The TRICARE health plan for military personnel and dependents directly reimburses CRNAs and anesthesiologists at the same rates, using similar payment modalities as the Medicare Part B program. Health plans offering benefits under the Federal Employees Health Benefits Plan (FEHBP) characteristically reimburse CRNAs directly for their services. Finally, most private health plans, including fee-for-service (FFS) plans, preferred provider organizations (PPO), health maintenance organizations (HMO), and health benefits administrators that are not health insurance programs per se, reimburse directly for CRNA services. References Social Security Amendments of 1965, P.L Tax Equity and Fiscal Responsibility Act of 1982, P.L Social Security Amendments of 1983, P.L Deficit Reduction Act of 1984, P.L Omnibus Budget Reconciliation Act of 1986, P.L Next Page

5 Reimbursement of CRNA Services (Continued) Omnibus Budget Reconciliation Act of 1987, P.L Omnibus Budget Reconciliation Act of 1989, P.L Omnibus Budget Reconciliation Act of 1990, P.L Omnibus Budget Reconciliation Act of 1993, P.L Medicare Improvements for Patients and Providers Act of 2008, P.L Medicare Claims Processing Manual, Chapter 12, Physician and Nonphysician Providers, Centers for Medicare & Medicaid Services, Baltimore, MD, clm104c12.pdf, accessed April 7, Medicare Claims Processing Manual, Chapter 4, Hospital Including Inpatient Hospital Part B and OPPS, Centers for Medicare & Medicaid Services, Baltimore, MD, downloads/clm104c04.pdf, accessed April 7, Survey of state Medicaid programs, unpublished, American Association of Nurse Anesthetists, May 2010 #