News
April 2021
New York BCBS policy change drives surgery to ASCs
Empire BlueCross BlueShield in New York updated its coverage policy this year to drive more surgical procedures to ASCs.
The policy was published Oct. 1 and went into effect Jan. 1. Empire commercial plan members now need a medical necessity review to have certain procedures performed in the outpatient hospital setting instead of an ASC.
"Empire BlueCross BlueShield is committed to being a valued healthcare partner in identifying ways to achieve better outcomes, lower costs and deliver access to a better healthcare experience for consumers," the payer wrote in the Oct. 1 announcement of its policy change.
The site of care review applies to a 33-page list of procedures, including gastroenterology, orthopedics, ophthalmology, auditory and nervous system procedures. There are 111 musculoskeletal procedures on the list, in addition to common procedures such as cataract surgery and colonoscopy.
Only procedures performed in the hospital outpatient setting are subject to the review; ASCs are not. The overall cost of care is typically lower for surgery centers than in hospital outpatient departments, and the move could be a boon for New York ASCs.
Read more: https://www.beckersasc.com/asc-coding-billing-and-collections/new-york-bcbs-policy-change-drives-surgery-to-ascs.html
Empire BlueCross BlueShield in New York updated its coverage policy this year to drive more surgical procedures to ASCs.
The policy was published Oct. 1 and went into effect Jan. 1. Empire commercial plan members now need a medical necessity review to have certain procedures performed in the outpatient hospital setting instead of an ASC.
"Empire BlueCross BlueShield is committed to being a valued healthcare partner in identifying ways to achieve better outcomes, lower costs and deliver access to a better healthcare experience for consumers," the payer wrote in the Oct. 1 announcement of its policy change.
The site of care review applies to a 33-page list of procedures, including gastroenterology, orthopedics, ophthalmology, auditory and nervous system procedures. There are 111 musculoskeletal procedures on the list, in addition to common procedures such as cataract surgery and colonoscopy.
Only procedures performed in the hospital outpatient setting are subject to the review; ASCs are not. The overall cost of care is typically lower for surgery centers than in hospital outpatient departments, and the move could be a boon for New York ASCs.
Read more: https://www.beckersasc.com/asc-coding-billing-and-collections/new-york-bcbs-policy-change-drives-surgery-to-ascs.html
RevCycle Intelligence (4/5, LaPointe) reports, “CMS has started recouping Medicare payments it fronted to [health care] providers last year during the COVID-19 pandemic.” CMS “stated that it has begun recovering the payments through the COVID-19 Accelerated and Advance Payments (CAAP) on March 30, 2021, and will continue recoupment depending on the one year anniversary of when providers received their first payment.”
February 2021
Will more payers buy ASCs? By Laura Dyrda - Becker's ASC Review
ASC industry leaders expect more consolidation in the coming years as the cost and risk of owning independent centers increases. How often will the buyer be a payer? Naya Kehayes, principal at ECG Management Consultants, expects more payer investments in the future. Payers with ownership in ASCs have access to the center's data and can directly funnel patients into the surgery center.
"Optum, a part of the UnitedHealth Group, owns SCA. Kaiser definitely has ownership in surgery centers, and there are other payers across the country that maintain ownership in surgery centers," she said during a session at the Becker's ASC Virtual Event in October 2020. "You're going to see more payers taking equity in a lower-cost delivery platform, because it creates alignment to reduce costs and influence further migration."
Optum acquired Surgical Care Affiliates in 2017 for $2.3 billion. At the time, SCA owned or operated 205 surgical facilities in partnership with about 3,000 physicians. Since then, the company has grown to operate more than 230 surgical facilities, and it added 1,000 more physicians to its network last year. The company also added more than 40 new service lines in 2020, doubling the number added in 2019. Read more
ASC industry leaders expect more consolidation in the coming years as the cost and risk of owning independent centers increases. How often will the buyer be a payer? Naya Kehayes, principal at ECG Management Consultants, expects more payer investments in the future. Payers with ownership in ASCs have access to the center's data and can directly funnel patients into the surgery center.
"Optum, a part of the UnitedHealth Group, owns SCA. Kaiser definitely has ownership in surgery centers, and there are other payers across the country that maintain ownership in surgery centers," she said during a session at the Becker's ASC Virtual Event in October 2020. "You're going to see more payers taking equity in a lower-cost delivery platform, because it creates alignment to reduce costs and influence further migration."
Optum acquired Surgical Care Affiliates in 2017 for $2.3 billion. At the time, SCA owned or operated 205 surgical facilities in partnership with about 3,000 physicians. Since then, the company has grown to operate more than 230 surgical facilities, and it added 1,000 more physicians to its network last year. The company also added more than 40 new service lines in 2020, doubling the number added in 2019. Read more
American Medical Association Guide to Surprise Billing Law
Click here for an initial guide to the major provisions in the “No Surprises Act,” the surprise billing legislation that was included in the Consolidated Appropriations Act COVID-19 relief bill signed into law on December 27, 2020. The No Surprises Act allows for price transparency, provider directories, and patient financial protections that impact health plans, physicians, facilities, and other non-MD/DO licensed health care professionals. The law goes into effect on January 1, 2022. The intent of the law is not to preempt state surprise billing laws. However, there is some ambiguity in the statutory language that will require further clarification before and during the rulemaking process, including when the surprise billing protections apply to patients in self-funded ERISA plans. The AMA will work with Federation members and other stakeholders to seek clarification to address these ambiguities and will revise this guide accordingly as new information becomes available.
Source: AMA
Click here for an initial guide to the major provisions in the “No Surprises Act,” the surprise billing legislation that was included in the Consolidated Appropriations Act COVID-19 relief bill signed into law on December 27, 2020. The No Surprises Act allows for price transparency, provider directories, and patient financial protections that impact health plans, physicians, facilities, and other non-MD/DO licensed health care professionals. The law goes into effect on January 1, 2022. The intent of the law is not to preempt state surprise billing laws. However, there is some ambiguity in the statutory language that will require further clarification before and during the rulemaking process, including when the surprise billing protections apply to patients in self-funded ERISA plans. The AMA will work with Federation members and other stakeholders to seek clarification to address these ambiguities and will revise this guide accordingly as new information becomes available.
Source: AMA
January 2021
Federal action on surprise medical bills: What doctors should know
Patients will be protected from unexpected medical costs, while out-of-network physicians other clinicians and facilities will have a process available to challenge inadequate out-of-network payment from commercial health insurance companies.
These provisions, which take effect Jan.1, 2022, are part of the No Surprises Act that was folded into the Consolidated Appropriations Act, 2021, a comprehensive, $1.4 trillion legislative package that included COVID-19 related relief for physicians and appropriations to fund government operations through the end of fiscal year 2021, which ends Sept. 30.
Read more: https://www.ama-assn.org/delivering-care/patient-support-advocacy/federal-action-surprise-medical-bills-what-doctors-should
Patients will be protected from unexpected medical costs, while out-of-network physicians other clinicians and facilities will have a process available to challenge inadequate out-of-network payment from commercial health insurance companies.
These provisions, which take effect Jan.1, 2022, are part of the No Surprises Act that was folded into the Consolidated Appropriations Act, 2021, a comprehensive, $1.4 trillion legislative package that included COVID-19 related relief for physicians and appropriations to fund government operations through the end of fiscal year 2021, which ends Sept. 30.
Read more: https://www.ama-assn.org/delivering-care/patient-support-advocacy/federal-action-surprise-medical-bills-what-doctors-should
CMS Puts Patients Over Paperwork with New Rule that Addresses the Prior Authorization Process
Today, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.
“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”
Read more: www.cms.gov/newsroom/press-releases/cms-puts-patients-over-paperwork-new-rule-addresses-prior-authorization-process
Today, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.
“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”
Read more: www.cms.gov/newsroom/press-releases/cms-puts-patients-over-paperwork-new-rule-addresses-prior-authorization-process
Extension of the PHE & Implementation of Medicare Payment Changes in Consolidated Appropriations Act
HHS Secretary Azar has extended the COVID-19 Public Health Emergency (PHE) declaration effective Jan. 21, 2021 for an additional 90 days. This means that all of the telehealth and other waivers and flexibilities that have been implemented during the PHE will remain in effect until at least April 21, 2021.
In addition, as indicated in the summary and impact table distributed earlier this week, the Consolidated Appropriations Act that was signed into law on Dec. 27, 2020, included provisions that offset most of the 10.2% budget neutrality adjustment that had been slated to take effect for Medicare-covered services provided as of Jan. 1, 2021. CMS has now confirmed that it is implementing the following provisions of this legislation and that there will be no delay in claims processing for 2021 services; that is, claims will be paid on time at the correct 2021 rates that reflect this legislation.
Message from CMS:
On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):
Source: AMA
HHS Secretary Azar has extended the COVID-19 Public Health Emergency (PHE) declaration effective Jan. 21, 2021 for an additional 90 days. This means that all of the telehealth and other waivers and flexibilities that have been implemented during the PHE will remain in effect until at least April 21, 2021.
In addition, as indicated in the summary and impact table distributed earlier this week, the Consolidated Appropriations Act that was signed into law on Dec. 27, 2020, included provisions that offset most of the 10.2% budget neutrality adjustment that had been slated to take effect for Medicare-covered services provided as of Jan. 1, 2021. CMS has now confirmed that it is implementing the following provisions of this legislation and that there will be no delay in claims processing for 2021 services; that is, claims will be paid on time at the correct 2021 rates that reflect this legislation.
Message from CMS:
On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):
- Provided a 3.75% increase in MPFS payments for CY 2021
- Suspended the 2% payment adjustment (sequestration) through March 31, 2021
- Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
- Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024
Source: AMA
Telehealth Claim Lines Increase 3,060 Percent Nationally When Comparing October 2019 to October 2020
Telehealth claim lines increased 3,060 percent nationally from October 2019 to October 2020, rising from 0.18 percent of medical claim lines in October 2019 to 5.61 percent in October 2020, according to new data from FAIR Health’s Monthly Telehealth Regional Tracker. From month to month, coinciding with a surge in COVID-19 cases in October, the telehealth share of medical claim lines rose 10.6 percent nationally, from 5.07 percent in September 2020 to 5.61 percent in October 2020. The data represent the privately insured population, excluding Medicare and Medicaid. Click here to read more
Source: Fair Health
Telehealth claim lines increased 3,060 percent nationally from October 2019 to October 2020, rising from 0.18 percent of medical claim lines in October 2019 to 5.61 percent in October 2020, according to new data from FAIR Health’s Monthly Telehealth Regional Tracker. From month to month, coinciding with a surge in COVID-19 cases in October, the telehealth share of medical claim lines rose 10.6 percent nationally, from 5.07 percent in September 2020 to 5.61 percent in October 2020. The data represent the privately insured population, excluding Medicare and Medicaid. Click here to read more
Source: Fair Health
What Stark law, anti-kickback changes mean for value-based care at ASCs
01/06/2021
HHS issued two rules on value-based care arrangements recently that will affect orthopedic surgeons and ASCs.
CMS made adjustments to the Stark law, and HHS updated the federal Anti-Kickback Statute and the civil monetary penalties law to ensure healthcare providers could develop value-based care arrangements without fear of fraud and abuse charges. The changes to the Anti-Kickback Statute make it easier to enter into value-based care arrangements, especially if providers take full risk.
Read more at: https://www.beckersasc.com
01/06/2021
HHS issued two rules on value-based care arrangements recently that will affect orthopedic surgeons and ASCs.
CMS made adjustments to the Stark law, and HHS updated the federal Anti-Kickback Statute and the civil monetary penalties law to ensure healthcare providers could develop value-based care arrangements without fear of fraud and abuse charges. The changes to the Anti-Kickback Statute make it easier to enter into value-based care arrangements, especially if providers take full risk.
Read more at: https://www.beckersasc.com
Anthem reportedly undergoing DOI ‘Market Conduct Review’
The Medical Association of Georgia (MAG) is receiving reports that Georgia’s Department of Insurance is conducting an “examination” of Anthem’s conduct in Georgia – so MAG is encouraging physicians and applicable practice staff to report every instance that Anthem has not fulfilled its contract obligations.
Georgia law states that, “The Commissioner may, when the Commissioner deems it reasonably necessary to protect the interests of the public, examine the business and affairs of any licensee or applicant for a license.”
MAG Corporate Relations Director Ryan Larosa explains that, “Georgia Insurance Commissioner John King has broad power to protect consumers, and we have been working with other physician/patient organizations to address Anthem’s inappropriate business practices. These conduct reviews can look at business practices from prior years, so physicians should report every instance that Anthem has not fulfilled its contract obligations.”
Physicians and practice staff should contact DOI’s Gregg Conley at gconley@oci.ga.gov to report every instance that Anthem has not fulfilled its contract obligations.
Contact Ryan M. Larosa, MBA at rlarosa@mag.org with questions.
The Medical Association of Georgia (MAG) is receiving reports that Georgia’s Department of Insurance is conducting an “examination” of Anthem’s conduct in Georgia – so MAG is encouraging physicians and applicable practice staff to report every instance that Anthem has not fulfilled its contract obligations.
Georgia law states that, “The Commissioner may, when the Commissioner deems it reasonably necessary to protect the interests of the public, examine the business and affairs of any licensee or applicant for a license.”
MAG Corporate Relations Director Ryan Larosa explains that, “Georgia Insurance Commissioner John King has broad power to protect consumers, and we have been working with other physician/patient organizations to address Anthem’s inappropriate business practices. These conduct reviews can look at business practices from prior years, so physicians should report every instance that Anthem has not fulfilled its contract obligations.”
Physicians and practice staff should contact DOI’s Gregg Conley at gconley@oci.ga.gov to report every instance that Anthem has not fulfilled its contract obligations.
Contact Ryan M. Larosa, MBA at rlarosa@mag.org with questions.
