Medicare Compliance & Reimbursement

Women could lose out from the new practice expense payments.

Some services will see drastic reductions in their practice-expense relative value units (PE-RVUs) according to the final regulation from the Centers for Medicare & Medicaid Services (CMS).

Many critics charged that CMS undervalued several essential services for women's health, including osteoporosis-detection techniques like bone density scanning. CMS based the costs for such techniques on pencil beam technology, which costs only around $41,000 instead of the $85,000 fan beam technology, which physicians more commonly use. CMS agreed to revise its estimates based on the cost of fan beam technology.
 
But the agency refused to reverse practice-expense cuts to several other services for women, including computer-aided detection (CAD) services (for mammographies), radiation therapy codes involved in breast brachytherapies, breast balloon catheter placement and surgical hysteroscopy. CMS noted some other mammography services were rising in payments and offered to ask the Relative Value Update Committee to review the bone-density and CAD values.

Commenters also complained that practice-expense cuts could reduce patients' access to cardiac care and that interventional radiologists would also suffer disproportionately.

Weak Data Hurts Doctors

Many physician groups expressed concern about the quality of the data CMS used in devising the new "bottom-up" practice expense rates.

In particular, some groups complained that some specialties that submitted their own "supplemental survey data" saw stark increases in their reimbursement as compared to other specialties. This threw the balance of Medicare payments out of whack, they argued. But CMS responded that the law required it to accept supplemental surveys from specialty societies.

Some specialties asked to have their practice-expense payments "frozen" over the next few years, but CMS refused.

The American Medical Association is devising a multi-specialty cost survey to help replace the single-specialty supplemental surveys, and CMS supports this effort. So far, 40 specialties have agreed to take part, CMS says.
 
The practice expense data doesn't include any accounting for uncompensated care, which drives up the costs of practicing medicine. CMS says it's including a special adjustment to emergency medicine PE-RVUs for uncompensated care, and maybe the AMA multi-specialty survey will include a question on this issue.

The Association of Freestanding Radiation Oncology Centers (AFROC) took issue with calculations that gave a higher weight for costs for hospital-based radiation oncologists than for freestanding radiation oncologists, resulting in a much lower overall payment level. CMS agreed with AFROC's comment and boosted radiation oncologists' practice expense per hour from $161.13 to around $209.

Some specific services were especially hard hit by the new PE changes, including cardiac event monitoring, which CMS agreed to base on cardiology costs instead of independent diagnostic testing facility costs. Physicians wanted direct PE inputs for some arthroscopy services, but CMS said those procedures weren't safe to perform in the physician's office.

Some providers argued that CMS undercounted hourly wages for audiologists and medical physicists, but CMS only boosted wages for medical physicists. CMS wouldn't boost costs for extracorporeal shock wave therapy because it didn't believe physicians needed extra staff for this procedure.