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CMS 2015 Global Period Proposal to Zero Days


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http://www.fiercehealthcare.com/story/doc-groups-have-mixed-reactions-cms-2015-medicare-physician-fee-schedule-pr/2014-07-07

 

I just read about this story in the STS newsletter, the above is link with other info

 

My practice is global payment (90 days, cardiac surgery). If this proposal is approved then it would have a major impact on our billing practice. PA visits and services would then be itemized.

 

Anyone else (S Hanson???) have any more info on how this may impact all PAs????

 

-Matt

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  • 3 weeks later...
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nothing current that I have knowledge of

 

heard them kicking this idea around as to many surgeons were blowing off follow up as it was in the global period - suspect they want the docs following up on the surgeries, no more sending everyone to the ER for simple complaints

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From Michael Powe at AAPA:

 

Hi Steve,

 

The new rules would require that the “new global surgical payment” consist of the pre-op and the intra-operative care. The 20% or so that is currently paid for the post-op care would be eliminated from the global surgical payments. Medicare would allow the professional who performed the post-op visits to bill separately for each office visit as a general E/M service.

 

PAs (and surgeons) in surgery may have some angst with the new rule, but the bottom line is that if the surgeon or surgical PA working for the surgeon perform the post-op work they still receive all of the money. If a patient needs fewer post-op visits there is less money available. If the patient needs more visits due to complications/acuity level then CMS would pay for as many visits as necessary.

 

PAs who are employed by hospitals (as opposed to the surgeon) and who have been doing a fair amount of the post-op work (somewhat illegally, I might add) with all of the money going to the surgeon/surgical PA, may feel differently. They will be recognized for the legitimate work they perform and for which they couldn’t bill.

 

From the standpoint of transparency this is positive thing for PAs, but it’s also a huge process change that I didn’t think CMS would pull off. These provisions go in place in 2017 for 10-day global codes and 2018 for 90-day codes. That means there is lots of time for surgeons to convince Congress to interfere.

 

Here are AAPA’s official comments on the proposal. We have to make sure that the first assist fee (which is a percentage of the global payment) is protected.

 

Elimination of the Post-Operative Surgical Global Period

AAPA supports the concept of increased transparency in knowing which health professional provides care to Medicare beneficiaries, but urges CMS to be aware of the potential for unintended consequences if the post-operative surgical global period is eliminated.

 

AAPA understands the conceptual framework behind the CMS proposal to eliminate all 10- and 90-day global payments in 2017 and 2018, respectively. Historically for surgical reimbursement, Medicare pays the surgeon a lump sum, also known as a global payment, covering the pre-operative history and physical, the intra-operative surgical procedure, and the post-operative care for a period of either 10 or 90 days depending on the particular surgical procedure. CMS is questioning the extent to which a surgeon or a qualified member of the surgeon’s team is actually performing the post-operative work for which they have been paid through the current global payment process. CMS also questions whether payment should be made for a pre-assumed number of post-operative visits (which the current system does) as opposed to paying for the actual number of visits required by the surgical patient.

 

CMS now proposes to make one reduced payment to the surgeon to cover only those services delivered on the day of surgery. Payments for any post-operative visit(s) would be made separately to the healthcare professional that performs the post-operative evaluation and management service(s).

 

This proposal represents a radical change in payment methodology that will have serious ramifications on surgical practices. As such, CMS should proceed with caution and assure maximum transparency to avoid unintended, negative consequences. While AAPA believes that the identification of, and payment to, the health professional that actually performs the post-operative services could improve payment accuracy and fairness we are also sensitive to the financial impact such a policy would have on both patients, surgical practices, and those who first assist at surgery.

 

In thinking about surgical patients, at present they receive post-operative visits with no additional charges as those visits are “included” in the global payment. If the CMS proposal is adopted these same patients who seek post-operative care might be subject to deductibles and/or co-pays each time they receive a post-operative visit. Depending on the rules of the patient’s health plan/insurance coverage and the number of post-operative visits needed, irrespective of who provides that care, patients could be subject to hundreds of dollars of additional expenses that they are not required to pay under the current system. That burden would be especially severe on patients at the lower end of the economic scale. Likewise, patients who are sicker or who have more complications could be forced to pay more money out of pocket as they would typically need more medical visits than those patients with fewer complications.

 

Equally concerning is the possibility that patients, in order to save money, would not access post-operative care services in a timely manner. The result could be medical complications, such as wound infections, which go untreated until a more acute intervention or a hospital re-admission was necessary impairing the patient quality of life and costing the system more money.

 

This proposed policy change is not specifically aimed at altering the reimbursement for first assisting at surgery. However, reimbursement for first assisting is paid as a percentage of the global surgical fee. If the surgical fee is reduced then those PAs and physicians who first assist would receive a reduced payment for their services despite the fact that their professional work and responsibilities has not changed. If this proposal is adopted CMS should increase the Medicare percentage paid for assisting at surgery to assure that there is no loss in payment for these vital services

 

 

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so now a PA will get credit for doing all the post op visits!

 

no longer it is just lumped into the global fee

 

the further we get away from PA salary being paid out of overhead the better we are

I could not agree with you more.

 

As a surgical PA who does all his own billing for first assist and pre- and post- op office visits, I will take a little less for the procedure, and bill for all the individual OP visits. In the current system, some times you win, and sometimes you lose. This is definitely an improvement. Surgical patients are all different, and require different approaches to post op care.

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I could not agree with you more.

 

As a surgical PA who does all his own billing for first assist and pre- and post- op office visits, I will take a little less for the procedure, and bill for all the individual OP visits. In the current system, some times you win, and sometimes you lose. This is definitely an improvement. Surgical patients are all different, and require different approaches to post op care.

 

I truly hope this cuts back on all the surgeons pushing their post op complication visits back onto the PCPs 

 

I got pretty tired of this and always figured it was they were not getting paid for the office visit, so why do it?

 

Now they can generate revenue on seeing their patient.  In my mind for the first 30 days after a surgery if the patient has a complaint affecting the area of the body that was operated on - it should be the surgeon office seeing the patient, not the PCP who has no idea what happened during the surgery...

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I truly hope this cuts back on all the surgeons pushing their post op complication visits back onto the PCPs 

 

I got pretty tired of this and always figured it was they were not getting paid for the office visit, so why do it?

 

Now they can generate revenue on seeing their patient.  In my mind for the first 30 days after a surgery if the patient has a complaint affecting the area of the body that was operated on - it should be the surgeon office seeing the patient, not the PCP who has no idea what happened during the surgery...

It is too bad that some surgical offices to do this to PCPs. We want to see our post ops for any and all complications and potential complications first, and then decide if it is a surgical problem or a primary care problem. Maybe this reform with help change what you are experiencing.

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I truly hope this cuts back on all the surgeons pushing their post op complication visits back onto the PCPs 

 

I got pretty tired of this and always figured it was they were not getting paid for the office visit, so why do it?

 

Now they can generate revenue on seeing their patient.  In my mind for the first 30 days after a surgery if the patient has a complaint affecting the area of the body that was operated on - it should be the surgeon office seeing the patient, not the PCP who has no idea what happened during the surgery...

With the strict data and outcomes tracking that we are susceptible to, we generally do not want a PCP managing a complication. Not as a disrespect to them, but rather

1) it's our complication (you break it, you bought it), and

2) generalists may "over-workup" a problem that may merit a more targeted approach

 

perfect example is a wound complication that the surgical team may manage as an outpatient, whereas a PCP/ED may admit. And our readmission rates increase. 

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From Michael Powe at AAPA:

 

PAs who are employed by hospitals (as opposed to the surgeon) and who have been doing a fair amount of the post-op work (somewhat illegally, I might add) with all of the money going to the surgeon/surgical PA, may feel differently. They will be recognized for the legitimate work they perform and for which they couldn’t bill.

 

Steve,

Do you know what illegality Michael is referring to?

Is this re: billing appropriateness for who is doing the work, or PA scope of practice?

Matt

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Steve,

Do you know what illegality Michael is referring to?

Is this re: billing appropriateness for who is doing the work, or PA scope of practice?

Matt

Matt:

 

The surgeon is getting paid for the procedure and the global. If another provider is doing the post op care (i.e., PAs employed by the hospital and not by the surgeon), then he or she is getting paid for something that they are not doing. I think that is what Mike is referring too.

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Matt:

 

The surgeon is getting paid for the procedure and the global. If another provider is doing the post op care (i.e., PAs employed by the hospital and not by the surgeon), then he or she is getting paid for something that they are not doing. I think that is what Mike is referring too.

Actually its a stark violation. If the PA is paid for by the hospital but the physician is billing for their services such as assist in surgery. Its also a Stark violation if hospital employed PAs do follow up care or discharges when the physician has paid for them as Steve mentioned. Tricia Marriott covered this in her presentation last year at AAPA. Innova paid out $500k a few years ago for this. For a physician to bill for PA services they have to have a W2 or 1099 relationship with the physician. The other illegal part is when hospitals put PAs on their part A expenses instead of part B.

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  • 2 weeks later...

The issue is that the hospital is inducing referrals with an improper benefit. The government really frowns on this. In Hospital A the physician does his procedure and has to pay his own PA to do post-op care. In Hospital B that post op care is provided by a hospital employed PA. The physician pockets more money by sending to Hospital B and is essentially being paid a kickback to send patients to Hospital B.

 

You can actually still have compliance issues if both are employed, but then we're down a rabbit hole with fair market value.

 

 

Sent from my iPad using Tapatalk

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