Surgery News - February 2009 - (Page 3) FEBRUARY 2009 • SURGERY NEWS NEWS The suit, which has been pending since 2000, alleged that UHG had been understating the “usual, customary, and reasonable” charges in payments to physicians and in reimbursing patients for out-of-network expenses. Under the class action settlement, UHG subscribers who submitted a claim for outof-network services and were not properly reimbursed are eligible to receive part of the settlement. Physicians also could be eligible to receive payment under the settlement if they were underpaid by UHG and did not receive the balance from the patient. But the biggest gain for physicians under both the AMA settlement and the agreement with the New York attorney general won’t be money, but the rebuilding of the trust lost between patients and physicians, said Dr. Nancy H. Nielsen, AMA president. When UHG and other insurers refused to pay the physician’s charge, they were telling patients that the charge was unreasonable, creating tension between the patient and physician, said Dr. Rectifying Consumer Payments Database • from page 1 able” rates as calculated by the Ingenix database. As a result, insurers would only pay a percentage of the lower “usual, customary, and reasonable” rate, leaving consumers to pay their own portion plus the balance of the bill. The investigation found that insurers were underpaying consumers for out-ofnetwork expenses by 10%-28% for medical services across the state. “For the past 10 years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry,” Mr. Cuomo said in a statement. “This agreement marks the end of that flawed system.” According to UHG officials, the agreement with the New York attorney general will help increase the transparency of information related to physi- cian fees for out-of-network services. “We are committed to increasing the amount of useful information available in the health care marketplace so that people can make informed decisions, and this agreement is consistent with that approach and philosophy,” Thomas L. Strickland, executive vice president and chief legal officer for UnitedHealth Group, said in a statement. “We are pleased that an independent not-for-profit entity will play this important role for the marketplace.” Just days after reaching an agreement with Mr. Cuomo’s office, UHG also settled a lawsuit with the American Medical Association and two state medical associations over the use of the Ingenix database. The $350 million settlement is the largest monetary settlement of a class action lawsuit against a single health insurer in the United States, according to the AMA. Michael H. Rosenberg, president of the Medical Society of the State of New York, which was part of the AMA’s class action lawsuit. “This was always a wedge between patients and physicians.” But not everyone sees these agreements as a victory for physicians and patients. Robert Laszewski, president of Health Policy and Strategy Associates LLC, a Washington-based consulting firm, said he doesn’t expect to see significant changes in the “usual, customary, and reasonable” rates based on the creation of an independent database. The fundamental problem for physicians is that, regardless of who calculates the usual rates, there is still a wide discrepancy between the in-network rates available to most patients and the out-ofnetwork rates paid by some, said Mr. Laszewski. Increased transparency could end up benefiting the insurance industry if it shows physicians charging significantly more when patients are out-ofnetwork. “I think the insurance industry has won,” he said. Reimbursement for Vein Cases Will Vary Widely in 2009 B Y P AT R I C E W E N D L I N G Else vier Global Medical Ne ws C H I C A G O — The setting in which open and endovenous therapies are performed will greatly influence physician reimbursement in 2009. Medicare reimbursement for most major inpatient vascular operations will increase by 3%-4%, whereas reimbursement for most office-based vein cases will decrease by about 10%, Dr. Robert Zwolak said at a symposium on vascular surgery sponsored by Northwestern University. For example, Medicare reimbursement for open abdominal aortic aneurysm surgery (CPT code 35081) is up by 3.9% this year, to $1,756, whereas reimbursement for carotid stenting (CPT 37215) is up by 3.6%, to $1,101. On the flip side, reimbursement for endovenous vein ablation performed in the office (CPT 36475) is down by 10.6%, to $1,699. Several factors are at play, including the creation of new venous codes, the elimination of the Medicare budget neutrality work adjuster, and a 5.3% reduction in the Medicare conversion factor, said Dr. Zwolak, an ACS Fellow who is professor of surgery at Dartmouth Medical School and Dartmouth-Hitchcock Medical Center in Lebanon, N.H. The three components of the Medicare reimbursement formula—work relative value units (RVUs), malpractice, and practice expenses—are multiplied by the conversion factor to derive a payment rate for each code. The conversion factor was $38.09 per RVU in 2008, and is $36.07 per RVU in 2009. The work adjuster was introduced in 2007 to bring overall Medicare expenditures down, and was applied to the physician work RVU portion of the formula. It’s difficult initially to understand how inpatient procedure payments could increase when the conversion factor has been reduced, but it all has to do with the elimination of the work adjuster, Dr. Zwolak explained. For the past 2 years, Medicare discounted physician work by almost 12%. Therefore, in cases with large physician work components, such as aortic aneurysm repair, the positive effect of eliminating the physician work adjuster is greater in magnitude than is the negative effect of the 5.3% conversion factor reduction, and payments for these large cases actually go up by several percentage points. In contrast, for cases with much more practice ex- pense than physician work, such as endovenous vein ablation, the negative effect of the conversion factor reduction is much greater than the positive effect of work adjuster elimination, and these payments go down, he said. RVUs are also assigned in part based on whether a procedure is performed in a “facility” (hospital), or a “non-facility” (meaning a physician’s office or similar location). Dr. Zwolak noted that when a procedure is performed in the hospital, Medicare and other payers must reimburse the hospital for a technical fee to cover the space, personnel, supplies, and equipment necessary to perform the procedure. In contrast, when a procedure is performed in the physician’s office, the technical fee—including the cost of all imaging—is rolled into the total payment to the physician. For CPT 36475, the physician’s total RVU assignment was 9.30 if the endovenous vein ablation was performed in the hospital, or a reimbursement of about $324 in 2008. If the same procedure was performed in the physician’s office, the total RVU was 50.69, with a corresponding reimbursement to the physician of about $1,900, Dr. Zwolak said. In 2009, total RVUs in the hospital setting are essentially unchanged, at 9.29, whereas total RVUs in the office setting will fall by about 7%, to 47.1, because of a reduction in practice expense. Thus, the reduction in total office-based RVUs, compounded by a 5% reduction in the conversion factor, results in a $200 pay cut for this procedure when it’s done in the office, Dr. Zwolak explained. “Medicare saves money when vein ablation is performed in your office, and with a $200 office-based pay cut in 2009, [the agency will] save even more,” he said. Introductory wording has been added to the 2009 CPT manual to remind physicians that all imaging is included in radiofrequency ablation and laser ablation CPT codes. Physicians should also be aware that the “global period” for endovenous procedures such as 36475 and 36478 is “0-day,” meaning that all evaluation and management work on the day of the procedure is bundled into a single prospective payment. However, when the patient returns for reevaluation on subsequent days, those office visits should be reported separately, Dr. Zwolak said. He noted the following specific issues: Procedures in search of a code. There are vein procedures without specific category I codes, such as subcutaneous vein maceration and foam sclerotherapy. The default or “unlisted” vascular surgery code 37799 can be used for vein maceration, whereas codes 36470/36471 can be used when a sclerosing agent is injected. Ultrasound guidance for sclerotherapy should be coded as 76937, and this requires image documentation and an accompanying written report, Dr. Zwolak said. Code 37799 is also appropriate for vena cava filter repositioning—another procedure without a specific code. Reimbursement for most inpatient Vena cava filter removal can be reported using CPT 37203 for reprocedures will moval of a foreign body. rise by 3%-4%, CPT codes 37765 and 37766 but will drop by were created for stab phlebectoabout 10% when done in an office. my of varicose veins with 10-20 stab incisions and more than 20 incisions, respectively. Code DR. ZWOLAK 37799 should be used to report stab phlebectomy with fewer than 10 stab incisions on an extremity, but many carriers will deny payment, he said. Modifiers are a must. Medicare will not pay for a diagnostic venogram during an intervention if a “recent” venogram has been performed. If you want to get paid for a diagnostic venogram performed at the same time as the therapeutic intervention, add a “-59 modifier” to the venogram, and be sure to dictate a full interpretation of the diagnostic portion of the study, Dr. Zwolak said. A “-26 modifier” should be used if you do not own the equipment or pay the staff. Coding and reimbursement resources. Key payment resources for physicians include the Medicare fee schedule, which ca http://www.cms.hhs.gov http://www.vascularweb.org http://www.sirweb.org
Table of Contents Feed for the Digital Edition of Surgery News - February 2009 Surgery News - February 2009 Contents The 20/20 Vision ICD-10 Looms News From the College: MedPAC Flak Oncology: Best for Breast General Surgery: Weighty Problem Surgery News - February 2009 Surgery News - February 2009 - Contents (Page 1) Surgery News - February 2009 - Contents (Page 2) Surgery News - February 2009 - Contents (Page 3) Surgery News - February 2009 - Contents (Page 4) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 5) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 6) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 7) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 8) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 9) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 10) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 11) Surgery News - February 2009 - Oncology: Best for Breast (Page 12) Surgery News - February 2009 - Oncology: Best for Breast (Page 13) Surgery News - February 2009 - Oncology: Best for Breast (Page 14) Surgery News - February 2009 - Oncology: Best for Breast (Page 15) Surgery News - February 2009 - Oncology: Best for Breast (Page 16) Surgery News - February 2009 - Oncology: Best for Breast (Page 17) Surgery News - February 2009 - Oncology: Best for Breast (Page 18) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 19) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 20)
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