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News to Note – November 2022

  • Last month, the Medicare Administrative Coordinator (MAC), First Coast Service Options, issued a notice that they are seeing an increasing number of claims for anesthesia services provided to patients receiving epidural or facet joint injections. Their medical directors feel that anesthesia is not needed for these procedures because, in their opinion, if the patient has a needle phobia, an oral anxiolytic should suffice. Is First Coast Service Options correct? This remains to be seen but it seems somewhat reasonable to question why it would be necessary for patients to require services from an anesthesiologist now when in past years it was not. Granted, colonoscopies in years past involved the gastroenterologist performing the procedure and also supervising the nurse providing IV sedation and now it is routine to have an anesthesiologist involved. The same argument could also be made for cataract extraction. What role does patient comfort and efficiency play in deciding if a service is necessary? Time will tell.
  • UHC recently released their new policy on Observation services which really is no different than the old policy. Once again, they say that observation is time-limited but then go on to say that their medical directors will determine if patients warrant, “an inpatient level of care.” As we know, “inpatient” is not a level of care. The care provided to inpatients is exactly the same as that provided to “observation patients.” “Inpatient” is a status and is appropriate for the patient who hits the end of the time allotted for observation but still requires ongoing hospital care. Now, if they want to say that ICU level of care is not appropriate or telemetry is not appropriate, that is perfectly reasonable. But, comparing inpatient and observation as if they are different levels of care does not make sense.
  • It appears the Centers for Medicare and Medicaid Services (CMS) is not happy about some celebrity ads for Medicare Advantage (MA) plans. CMS used secret shoppers who called the phone numbers associated with those advertisements and found a lot of incorrect information was being passed along to callers along with attempts to coerce enrollment. They also noted concern over recent national television advertisements promoting MA plan benefits and cost savings which may only be available in limited service areas or for limited groups of enrollees, overstate the available benefits, or use words and imagery that may confuse beneficiaries or cause them to believe the advertisement is coming directly from the government. CMS will now require MA plans to submit their advertisements for review and if CMS objects under the File and Use process within 45 days, the MA plan cannot proceed. CMS also announced that starting in 2023, they will increase their oversight of all other advertising and investigate more complaints by listening to the call recordings to see if misleading information was provided.
  • ACPA past presidents Drs. Charles Locke and Edward Hu along with ACPA Update editor Dr. Ronald Hirsch had several discussions about how Medicare calculates DRG payments to hospitals in preparation for a paper they published comparing payments in Maryland’s unique payment system to the DRG system. For many years, CMS had a pricer that could be downloaded and used to calculate payments. Amazingly, until last year, the pricer only worked with computers that had COBOL, a programming language that was first used in 1959. CMS finally developed a web-based system to enter the 21st century. But, it turns out that when they moved it from COBOL to the web, they made a mistake. They left out the daily pass-thru payment to teaching hospitals. Dr. Locke was able to contact the CMS programmers and explain their omission leading to CMS updating the pricer. So, now if you use the web pricer, you will see the label “paid DRG with per diem,” and you can thank Dr. Locke!
  • The latest quarterly Cigna newsletter has announced they have sold access to their provider network to Kaiser Permanente. This means when a Kaiser patient, who is outside the normal Kaiser service area, seeks emergency care, if that provider is contracted with Cigna, the patient will be considered at an in-network hospital. As such, the provider will be obligated to accept Cigna rates and follow the Kaiser notification process. Kaiser wins in that it no longer has to pay out-of-network rates, Cigna wins in that you can be sure they are getting paid generously for that network access, and the providers lose by having to follow a more onerous process and get paid less than they would have received prior to this collaboration.

**The news above in addition to many other points of interest for Physician Advisors and other leaders in health care can be heard weekly during Dr. Ronald Hirsch’s Monday Rounds segment on’s Monitor Monday webcast/podcast. Learn More

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