Should nurses be allowed to administer anesthesia without a doctor’s supervision?

This is a debate that’s been plaguing hospitals around the country. It started in 2001 with a change to Medicare and Medicaid regulations. The change allowed states to opt out of a requirement that nurse anesthetists be supervised.

Many believe this is a good change. Reason: It gives increased access to healthcare for people in rural areas who have to travel outside their local community to find a facility that has an anesthesiologist.

The two sides of the debate are:

• Nurse anesthetists, who specialize in administering anesthesia. Argument: They are highly capable of administering anesthesia without the supervision of a physician, because they learn about the same drugs, equipment and standards of care as physicians do.
• Anesthesiologists, who are physicians who specialize in administering anesthesia. Argument: Anesthesia is a complex and technically demanding area of medicine that requires the skill of a physician, or at least the supervision of a physician, in case complications arise.

Colorado is one of 17 states that have decided to allow nurse anesthetists to administer anesthesia without physician supervision. Due to this decision, the state finds itself embroiled in a legal battle.

In 2010, anesthesiologist and medical societies filed a lawsuit in state court. The lawsuit asserted that allowing nurse anesthetists to deliver anesthesia without supervision wasn’t consistent with state law — a requirement for opting out of the federal rule.

However, the lawsuit was dismissed. A judge ruled the legislature did intend for the practice to be allowed. But that didn’t stop the medical societies. They appealed the ruling last May. Nationally, both sides are keeping a close watch on this case.

Colorado isn’t alone. The California Society of Anesthesiologists petitioned the State Supreme Court to take another look at its 2009 lawsuit for opting out of the supervision requirement. Much to the chagrin of the California Hospital Association, the suit hasn’t been successful. The association is on the nurses side due to the difficulty it’s had staffing anesthesiologists in facilities in California’s rural areas.

Where does your facility stand on this debate? Share thoughts in the box below.

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Transcatheter aortic valve replacement (TAVR), which allows doctors to replace a patient’s aortic valve through a small opening in the leg, is less invasive and gives patients who normally can’t undergo open heart surgery a fighting chance at survival.

The announcement of the coverage decision on May 1, is one of the first under a mutual memorandum between CMS and the FDA to get new, lifesaving technology to patients sooner.

To offer this procedure to patients, certain provider, facility and data collection criteria have to be met. Reason: It’s still a fairly new technology, and CMS and the FDA want to make sure these procedures are done by highly trained professionals in facilities that are well equipped so patients receive the safest and best care possible.

That’s why the decision states the procedure is covered under “Coverage with Evidence Development.”

The procedure will be covered for the treatment of symptomatic aortic-valve stenosis when the following five conditions — each of which has its own criteria — are met:

• The procedure is performed with a complete aortic valve and implantation system that has received FDA pre-market approval for that system’s FDA approved indication.
• Two cardiac surgeons have independently examined the patient’s suitability for open aortic valve-replacement surgery.
• The patient is under the care of a heart team: a cohesive, multidisciplinary team of medical professionals.
• The heart team’s interventional cardiologists and cardiac surgeons must jointly participate in the intraoperative technical aspects of TAVR, and
• The treating team and hospital must participate in a national registry that enrolls TAVR patients and tracks the following outcomes: stroke; all-cause mortality; transient ischemic attack; major vascular events; acute kidney injury; repeat aortic valve procedures; and quality of life.

TAVR is covered for uses that aren’t listed as an FDA-approved indication, but only when done within a clinical study that meets required conditions.

For the complete list of all the conditions, click here.

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“Wrong setting” denials – where a RAC audit determines that services were provided in a medically unnecessary setting.

So why are RACs targeting hospitals?

It’s simple – it’s lucrative. The Centers for Medicare & Medicaid Services (CMS) pays a contingency fee to RACs for finding and collecting overpayments. So they go after high-dollar inpatient services.

According to Craneware InSight’s whitepaper, RAC Best Practices: Utilization Management, many facilities make themselves easy targets for RACs because they only use one set of criteria to assess inpatient admissions.

To “RAC-proof” your facility’s admission screening criteria, industry expert Karen Bowden, RHIA, who has 25 years of hospital administrative experience, suggests hospitals use the following three steps to supplement published inpatient screening criteria:

1. Adopt All procedures on “inpatient only” published lists from Medicare, payors with such lists, and ones in proprietary screening criteria.
2. Have your utilization review committee develop and approve leveling criteria for all procedures that, depending on the circumstances, can be performed and billed as an in- or outpatient. When researching these procedures, look for diagnosis combinations that can increase the risk of complications and death, and require additional monitoring and/or interventions.
3. Implement a second-level review by a case manager. The cases that should undergo a second-level review include those that:
   • don’t meet “inpatient status” admission screening criteria, but the case manager believes — based on clinical documentation — should be classified as inpatient
   • are categorized as inpatient, but the original case manager feels should be observation status. In these cases, if the second-level reviewer agrees, the cases go to a physician advisor before any status changes are made, and
   • involve observation patients in a nursing unit bed.

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The Centers for Medicare & Medicaid (CMS) has some answers.

First off, to avoid payment delays, you need to register for the program as soon as possible. If you’re not sure what’s needed to register, here’s a list for hospitals and professionals:

Professionals

• National Provider Identifier (NPI)
• National Plan and Provider Enumeration System (NPPES) User ID and Password
• Payee Tax Identification Number (if you are reassigning your benefits)
• Payee NPI (if you are reassigning your benefits)

Hospitals

• CMS Identity and Access Management (I&A) User ID and Password
• CMS Certification Number (CCN)
• National Provider Identifier (NPI)
• Hospital Tax Identification Number

A hospital may qualify for both the Medicare and Medicaid EHR Incentive Programs if it meets all of the following qualifications:

• It’s a subsection (d) hospital in the 50 U.S. States or the District of Columbia, or it’s a Critical Access Hospital (CAH)
• It has a CMS Certification Number ending in 0001-0879 or 1300-1399,  and
• 10% of its patient volume derives from Medicaid encounters.

Note: Hospitals that are eligible for both programs should select “Both Medicare and Medicaid” during the registration process, even if they plan to apply only for a Medicaid EHR incentive payment. Dually-eligible hospitals can attest through CMS for their Medicare EHR incentive payment at a later date, if they want to.

Hospitals that fall into one of the following three categories only qualify for the Medicaid EHR Incentive Program:

• Children’s hospital
• Cancer hospital, or
• Acute-care hospital in the U.S. territories.

When registering, facilities should select “Medicaid-only” for the hospital type and select their state from the drop-down menu. Not all states have launched a Medicaid EHR Incentive Program yet. Facilities that aren’t sure about their state can check its status here.

Eligible professionals who qualify for both the Medicare and Medicaid EHR Incentive Programs must select which incentive program they want to participate in during registration. And if they want to switch to the other program before 2015, they only can do so once after the first incentive payment is initiated.

For eligible hospitals and professionals who need more help, CMS offers a step-by-step guide.

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Years ago, physicians and their facilities didn’t have to worry all that much about identity theft. But nowadays, it happens more than you may think – unscrupulous individuals acquire providers’ identification and use it to commit fraud.

The good news is, there’s a new way to protect providers from the mayhem identify theft can cause.

The Centers for Medicare & Medicaid Services (CMS) created the provider victim validation/remediation initiative. It assists providers whose ID has been stolen and used to defraud federal healthcare programs.

Program integrity contractors assigned to different regions investigate the situation, after being notified by a potential victim. The American Medical Association (AMA) lists contact information for the contractors on its website.

These contractors investigate providers’ complaints, and generate a report to CMS for a final decision on whether to relieve providers of fraud liability based upon the evidence.

Providers who haven’t suffered any financial liability yet, but suspect they have been an identity theft victim, should contact their Medicare Administrative Contractors (MACs) or the Department of Health and Human Services Office of the Inspector General (800-HHS-TIPS).

In the past many physicians haven’t been able to clear their names and struggled to get their reputation and finances back on track, since there wasn’t an entity to help them. And not being able to clear up bad debts from fraudulent billing had devastating effects.

In addition, this kind of illegal access compromises privacy issues and causes HIPAA violations  — something no facility wants to deal with.

Now this new streamlined process gives physicians the help and resources they need when facing a devastating and complicated issue like identity theft.

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The deadline for complying with the new standards was Jan. 1, and that hasn’t changed.

What has changed is CMS originally said it wouldn’t start initiating enforcement of the new standards until March 31. But now after numerous complaints from providers poured in, stating the conversion was “significantly delaying” claim submission and payment, CMS offered a compromise by extending the grace period.

Now, non-compliant medical practices, hospitals and other healthcare entities have until June 30, 2012, to work out any remaining issues, fix technical glitches and become compliant with the new 5010 transaction standards.

While becoming compliant has been challenging for facilities and their IT departments, HIPAA 5010 is supposed to offer hospitals reduced administrative burdens and streamline their revenue cycle.

CMS predicts that after this enforcement extension is over, 98% of claims submitted at that point will be compliant.

Why’s CMS so optimistic?

It seems that many organizations have been making great strides in achieving HIPAA 5010 compliance and just need a little more time to work out the kinks.

If you’ve already achieved compliance, great. But if you’re still in the process and experiencing some difficulties, here are some things to watch for that could cause your claims to be denied:

• A National Provider Identifier (NPI) needs to be used, not a tax ID or Social Security number.
• P.O. boxes aren’t allowed on the claims, a street address is required and a nine-digit zip code is required.
• A maximum of 12 diagnosis codes can be on each claim, however, each specific service can only have four codes.
• Any unlisted CPT or HCPCS code must have a code description.
• A Medicare Secondary Payer (MSP) indicator must be submitted on the primary and secondary claim when Medicare is the secondary payer, and
• Drug quantity and unit of measurement are required when a National Drug Code is listed.

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But delay doesn’t mean abandon, and industry experts are urging facilities to continue preparations for switching to the new code set.

So make the most of the reprieve.

To put things in perspective, it took attendees at a recent coding boot camp four hours to code 20 cases in ICD-10 – and that was with the help of the instructor.

It’s estimated that coding will take twice as long under ICD-10 – at least initially – resulting in a 10% to 25% loss in coding productivity.

An update on ICD-10 is expected from HHS soon. Until then, this four-step plan can help you make the most of the extended prep time:

1. Plan a strategy. Create a plan for dealing with reduced coding productivity. Consider how you’ll tweak the workload to offset the loss (offer overtime pay, hire more coders, outsource some of the work, etc) and how that will affect your practice financially.
2. Review all written procedures and policies concerning coding. Look for any documents that will need to be updated to reflect ICD-10 changes. Note: The Centers for Medicare & Medicaid Services (CMS) has some helpful resources at www.cms.gov/ICD10.
3. Review payor contracts. Since contracts are based on the current ICD-9 codes, your practice will need to work with carriers to update them for ICD-10. Don’t assume they’ll do it for you.
4. Establish a line of credit. The switch to ICD-10 will certainly affect cash flow, and most lines of credit need to be in place for six months to a full year before funds become available.

Think of it this way: If you use this time now to get up to speed on ICD-10, the switch to ICD-11, which is coming in 2015, won’t seem so bad.

Is your facility ready for ICD-10? Share your preparation plans for the future in the comments area below.

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One expert estimated a legitimate practice would have to be treating a million patients at 30 locations to justify the kind of billings Roy racked up.

Prosecutors say Roy and his office manager paid so-called recruiters $50 a pop to go door-to-door in neighborhoods, asking the residents to sign off on forms stating the doctor had treated them in their homes. The recruiters also signed up residents at local homeless shelters.

The office manager and the owners of five local home health agencies were also charged in relation to the fraud. Additionally, $2.3 million in payments to 78 other home health agencies were suspended.

Federal officials discovered the fraud through the use of new data analysis tools intended to catch unusual billing practices or trends. For an example of what kinds of data could be a red flag, 99% of doctors have certified 104 or fewer patients for home health care. Roy had certified more than 5,000.

If convicted, Roy faces a maximum sentence of 100 years in prison and a minimum of $18.5 in fines.

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It’s not official yet, but the House and Senate have reached a compromise agreement. The bill is expected to be voted on before President’s Day.

A nearly 28% cut to physicians’ Medicare payments was scheduled to take effect March 1. Under the proposed plan, physicians will get a 0% “payment update,” essentially leaving them at the same payment level. It’s good news, although certainly most doctors would have preferred even a slight increase in payments.

Of course, Congress now has to make up that money somewhere. So the proposal includes other cuts such as:

• inpatient acute care hospitals will see Medicare bad debt payments reduced to 65% beginning in 2013
• critical access hospitals will see  payments reduced to 65% over the next three years
• a reduction in Medicaid Disproportionate Share Hospital payments in 2021.

What the proposal doesn’t change are payments for evaluation and management services provided in hospital outpatient departments or rules regarding physician self-referral.

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A new report by federal analysts found that the reduced spending in 2010 (the last year for which data is available) was due to a combination of high unemployment, lower household income, a reduction in the number of people with private insurance and some folks opting to skip needed care (or choose cheaper options) because they simply couldn’t afford the preferred treatment.

According to the report by CMS, in 2010, health spending grew just 3.9%, only 0.1 percentage point faster than 2009. Total health spending in 2010 was $2.6 trillion, about $8,402 per person. To date, 2009-2010 had the slowest rate of growth of any two-year period in the 51 years this data has been tracked.

More troubling, although this rate is “slowing,” health spending still grew exceptionally faster than the rest of the economy. About 45% of the spending was shouldered by government agencies at all levels — up from 41% in 2009. That increase is largely the result of growing Medicaid enrollment and enhanced federal matching rates from the American Recovery and Reinvestment Act.

At the household level, spending was up 2.8% in 2010. One-third of such spending was employee contributions to private health insurance. People weren’t necessarily getting more for their money though. A significant portion of the increased spending was due to higher cost-sharing requirements for some employees, a trend toward plans with higher deductibles and/or co-payments, and many people having to pay out-of-pocket for health care after losing their health insurance coverage.

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