SCGhealth Blog

Digital Reality: X-Ray payment changing to push tech

Thursday, April 07, 2016

In an effort to create a faster and more efficient workflow among physicians and their ability to view and share x-rays, the Medicare rate on computed radiography (CR) will be reduced to encourage providers to begin to use digital radiography (DR). Payment reductions will also be made on analog equipment but that is not expected to have nearly the impact that the CR reductions will. Many facilities upgraded to CR before DR was an option, and therefore today there are thousands of CR equipment being used in the United States.

What made the change come about?
Officially the reductions will come from provisions that were inserted into the Consolidated Appropriations Act of 2016, which was enacted into law in December 2015. The idea comes with the promise that the use of CR will speed workflow and create an environment that is more efficient for providers and patients alike. 

How will the reductions work?
Beginning in 2017 reductions will be made on payments for any imaging done on analog machines. Starting in 2018, payments for imaging studies performed on CR equipment would be reduced by 7% for the next five years, and 10% after that. Imaging facilities will therefore have to decide whether to:

1. Spend the money to upgrade their CR equipment to DR (with integration into your certified EMR system) or

2. Not get paid as much. The anticipated reductions are between 7-10% in Medicare payments for x-ray studies beginning January 1, 2017. The proposed changes in the relative value units will be published in the proposed rule due out on or about July 1, 2016.

What about the patients?
The move to CR not only enables the patient to have quicker, more effective access to images, but it also exposes patients to less radiation then its counterparts. The biggest effect the new pay rates will have on patients is the ripple effect the lower pay rates from Medicare will have on providers and facilities already relying on slim resources.

What does this mean?
What it means is that the medical industry is making another step in the direction of efficiency as an unfunded mandate. What it also means is that a large number of facilities will have an expensive decision to make. Digital is clearly where medicine is headed, so the payment penalties could force some to bite the bullet quicker then they might have and invest in the latest and greatest the x-ray industry is offered. However, for those who cannot simply cannot afford to upgrade at this time, they will have to bear the brunt of the penalties until they are able to switch. For facilities that already struggle for funding these penalties could add up quickly and affect their ability to function.

How does the Supreme Court ruling on the Affordable Care Act affect providers?

Monday, June 29, 2015

By Marla Durben Hirsch

As you’ve probably heard by now, The United States Supreme Court ruled June 25 in King v. Burwell that the insurance premium tax credits, also known as subsidies, apply to both federal and state-run health insurance exchanges created by the Patient Protection and Affordable Care Act. The challengers had argued that the subsidies only applied to state-run exchanges, also called marketplaces, because the Act allowed subsidies for people in exchanges “established by the state.”

The court disagreed. In a 6-3 ruling affirming the lower courts’ decisions, Chief Justice John Roberts, writing for the majority, found that Congress meant the subsidies to apply in every state regarding of who was running the exchange. Noting that the Act grew out of a “long history of failed health instance reform” and that the words “established by the state” needed to be read in context, he said that applying the subsidy only to state-run exchanges would “likely create the very ‘death spirals’ that Congress designed the Act to avoid” and that it was “implausible” that Congress intended that result.

The ruling is also based on an analysis of the Act itself, not on deferring to federal agencies to fill in ambiguous Congressional gaps (known as “Chevron deference”). This means that the ruling is stronger, since it can only be overturned by legislation or executive order, not simply by a federal agency’s change of interpretation in the future.

The ruling retains the status quo at present, enabling people to continue to enjoy the subsidies no matter which exchange they’re obtaining insurance from. We won’t be seeing a wide-scale disruption in the industry, a roll back to the pre-Affordable Care Act era or some new program being instituted.

About 85 percent, or 8.7 million low and middle income people are receiving a premium tax credit to make their health insurance more affordable, according to the Kaiser Family Foundation.  Only 14 states run their own exchanges; 34 of them use the federal exchange.  More than six million people would have been adversely affected had the Supreme Court ruled against the subsidies.

This is a big win for President Obama. The administration, consumer groups and others have praised the ruling.

What does the decision mean for providers?

Not surprisingly, providers are pleased with the ruling. For instance, the American Medical Association is “relieved”:

 “The subsidies upheld today help patients afford health insurance so they can see a doctor when they need one and not have to wait until a small health problem becomes a crisis. The subsidies provide patients with peace of mind that they will not risk bankruptcy should they become seriously ill or injured and experience catastrophic health care costs.”

National Home Care and Hospice called the ruling “the best possible result we could have reasonably expected. Any other result would have led to wholesale chaos for the health care system.”

From a practical matter, the ruling means that since more consumers will have health insurance, there will be fewer uninsured making payment more predictable for providers. And arguably as these previously uninsured start availing themselves of preventive and follow up care that they hadn’t used previously, so they may be less sick when they come in for treatment, hopefully making them easier to treat.

However, since many of the plans on the health insurance exchanges also carry high deductibles, these consumers may also be underinsured, and providers will still be on the hook to collect these amounts directly from patients, who may have financial trouble making them.   Moreover, providers will still need to deal with the managed care plans offering their products on the exchanges.

And as the ruling makes it even more unlikely for the Affordable Care Act to be repealed, the other provisions of the law that increase burdens on providers, such as the 60 day deadline to return Medicare and Medicaid overpayments, the “open payments” program publicizing payments made by pharma and device manufacturers to physicians, the employee insurance mandates on practices as employers, and the like also remain in place.


Supreme Court decision:

Kaiser Family Foundation report:

Fee schedule keeps fees flat until April dip, deals additional changes

Monday, November 17, 2014
The 2015 conversion factor set to be implemented on Jan. 1 will dip slightly from 2014, going down to $35.8013 from $35.8228, the Centers for Medicare & Medicaid Services (CMS) announced in its release of the 2015 Medicare Physician Fee Schedule Final Rule.

The real problem comes April 1, when the conversion factor dips to $28.2239, a 21.2 percent cut, as provisions from the Protecting Access to Medicare Act (PANA) are set to expire without further Congressional action. 

It’s likely that Congress will stave off the cut, though how remains uncertain. The point of the latest legislation was to allow time to craft a bipartisan solution to the ongoing patches being made to the payment formula. The election results, as well as the looming 2016 presidential election, add uncertainty to that timeline.

The conversion factor is just one of the big changes detailed in the final fee schedule. Here are some other finalized changes you need to know about:

Chronic care management
CMS finalized with some modifications its plan to pay for monthly chronic care management services starting in 2015. Providers will bill new CPT code 99490 for calendar month chronic care management of at least 20 minutes, for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient. These conditions must put the patient at risk of death, functional decline, or acute exacerbation. 

The service will pay about $41 per month on a national average basis. Services do not need to be provided face-to-face, and vendors are already beginning to offer support services to physicians to track the monthly time and aid with clinical support, because CMS does not require the clinical services to all be provided by a practice employee. 

Patients do need to be informed that the service is being billed on their behalf and to authorize the sharing of health information with outside clinical providers. Patients may also revoke the ability to bill the service at any time. 

Place of service
CMS plans to do away with place of service (POS) code 22 for outpatient hospital services. In its place will be a new POS code for outpatient services rendered in the hospital, with a separate code for provider-based practices. The agency wants to track the migration of physician services to the provider-based setting and the POS codes will help with that effort. The code switch will not be done prior to July 1, 2015, and ample notice will be given about the switch.

The agency also created a new modifier, PO, for use on provider-based services. It is voluntary in 2015, but is expected to be required starting in 2016.

Physician Quality Reporting System (PQRS)
Most providers will be required to report at least nine measures in 2015, in order to avoid a 2017 penalty. This includes what is described as a “cross-cutting measure,” which is related to the development of a care plan for elderly patients. 

The nine measures will come across three quality domains. In addition, there will be approximately 20 new measures next year, with close to 50 measures set to be deleted. 

Global surgery
CMS plans to move ahead with plans to eliminate 10-day global periods in 2017 and 90-day global periods in 2018, replacing them with 0-day global periods including only work done on the day of the procedure.

The agency plans to work with the AMA’s Relative Value Update Committee (RUC) to ensure appropriate prices for the codes as the shift occurs. 

Group obesity counseling
CMS modified, then finalized a plan to create a new G code for group counseling provided to obese patients. Payment is crosswalked to medical nutrition therapy code 97804, which pays $15.17 for 30 minutes.

Revised malpractice RVUs
Malpractice RVUs will change in 2015 as part of a five-year review process. Among the changes being made are that CMS will combine neurosurgery and neurology data for malpractice risk, crosswalk interventional pain management to anesthesiology as proposed and crosswalk non-physician practitioners to allergy/immunology as proposed. 

Film to digital transition
CMS will begin basing payment for X-rays and other imaging services on digital price inputs, rather than analog film, reflecting the current practice of medicine. As a result, the agency will not eliminate its G codes for screening mammography, G0202-G0206, but will revise the codes to reflect that they are for 2-D mammography, not 3-D mammography.

Work, practice expense surveys are your opportunity to influence payment

Wednesday, March 19, 2014

You’ve probably heard by now some variation of the old saying, “If you don’t vote, then you can’t complain.”

The same could be said for the surveys providers are asked to fill out to gauge the typical patient visit to help assign the correct work and practice expense values used to determine the amount of the payments made by Medicare and private health care payers.

The surveys may seem burdensome, but for the average physician provider, they’re the best change to ensure that the payment for a given service is a fair and accurate assessment of the time it takes the provider, the intensity of the service and, for services done in the physician office setting, an accurate accounting of the expenses the practice spends on supplies and staff to complete the service. 

Look at it this way – there is a finite amount of money that Medicare or any other payer is willing to spend on health care services. When the work and/or practice expense values are increased for one service, the increase won’t be funded with new money, but from decreases to the values assigned to other services. 

It’s a little bit different from thinking about the amount of the conversion factor used to set payments. Think instead of the hierarchy of services you might see in a coding book. The surveys are the best chance that the AMA, specialty societies and CMS have to get it right. 

AMA’s RUC survey The survey instrument used to collect the work and practice expense data from providers is the AMA’s Relative Value Update Committee survey. The AMA administers the survey through individual specialty societies, directed to the physicians within those specialty societies.

Providers who are asked to participate will be notified by email, with a due date for the response included in the email.

The survey will ask that the provider compare the time, complexity and work to perform the service being surveyed to an existing survey and provide a list of possible reference procedures for comparison purposes.

The whole survey process is managed by the AMA’s RUC, even though the surveys are sent by the specialty societies. What happens is, the responses are tabulated by the specialty societies, which then make recommendations to the RUC for changes to the work, practice expense and professional liability values.

The RUC meets three times annually to consider the recommendations. Once the RUC signs off on the recommendations, they are presented to CMS. It’s CMS that ultimately decides whether to go forward with any changes.

When the values are changed, CMS communicates the results through the Medicare Physician Fee Schedule. 

The survey is broken down into six steps, which we’ll describe here:

  • Review code descriptor and vignette: The vignette will describe a typical clinical scenario and patient for a procedure. Complete it for the typical patient provided by the specialty society, though you may also include in your response that you don’t believe the patient represented is a typical patient.

  • Review introduction and complete contact information: This is the basic contact information for the survey responder, which is not forwarded to the AMA.

  • Identify a reference procedure: A list of similar procedures to the one being surveyed is provided for reference. The responder will choose the procedure that he or she believes to compare most favorably to the surveyed procedure. The reference procedure does not have to be an exact match in work, but should be similar. Factors such as the global period should be considered.

  • Estimate the time: The response here is an estimate, based on personal experience, of the amount of time it takes to complete the procedure. For operative procedures, this is broken down by the pre-procedure work, which includes services such as the hospital admission work-up, patient preparation and pre-procedure evaluation. It does not include the service that resulted in the decision for surgery. The intra-service work is defined as all of the “skin to skin” work in the procedure. The post-operative work is physician services provided on the day of the procedure after its completion, such as visits on the day of the procedure, communication with the patient, other health care professionals and the patient stabilization in the recovery room.

  • Compare the procedure to a reference procedure for intensity and complexity: Here, the respondent is asked to think about each component of the service and how they compare to a reference procedure. Among the items being surveyed for here are the time it takes to perform the service; the mental effort and judgment necessary based on the clinical data that needs to be considered, the number of potential decisions and the degree of complexity in evaluating the range of decisions; the technical skill required in terms of knowledge, training and experience needed to perform the service; and the psychological stress involved considering the potential for adverse outcomes based on the skill and judgment being made and potential unpleasant conditions such as higher rates of mortality associated with the service.

  • Moderate sedation: Whether there is a need for moderate sedation to be provided as part of the service. This does not include any work done separately by an anesthesiologist.

  • Estimate a work RVU: Based on the other steps of the survey and the selected comparative procedures, the physician will be asked to estimate a work RVU for the procedure. 

Practice expense refinement
As noted above, in addition to collecting data on physician work values, the RUC also has a role in surveying and helping to refine the practice expense RVUs that are part of the physician payment structure.

Currently, the RUC has a practice expense subcommittee focused on refining practice expense values, working with specialty societies and CMS to do so.

These efforts arose out of the Practice Expense Advisory Committee (PEAC), which had been established in 1998 to essentially undertake a process similar to the one the RUC committee uses for work values. 

As noted by the AMA, by the time its work was officially completed in 2004, the PEAC had overseen adjustments to practice expense values for close to 6,500 codes. 

The subcommittee that took its place still meets three times a year to consider changes to the factors such as clinical activity, medical supplies and equipment that make up practice expense. The subcommittee also looks at relativity, which is making sure that the practice expense input hierarchy makes sense. 

And certain practice expense data continues to be collected as part of the RUC survey process and specialty societies themselves survey practice expense data. It’s critical to respond, as some specialties have previously had their practice expense adjusted to a level providers considered to be unfair because the specialty didn’t have enough survey data to make a compelling case for an adjustment to CMS.

Because there is not currently a robust, national survey focused solely on practice expense, these data points become more challenging to correct later.

Which brings us back to the point where we started. If you don’t take the time to complete these surveys, it’s harder to complain about the results later.

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