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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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