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Medicare Reimbursement


Title: Identify the issue/problem. Author: liblab01 Last modified by: Brian Brister Created Date: 7/17/2007 8:58:55 PM Document presentation format – PowerPoint PPT presentation

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Title: Medicare Reimbursement

Medicare Reimbursement
  • Professional Aspects
  • MSNA 699
  • SRNA Project Summer 2007
  • Brian Brister
  • Gary Boutwell
  • Errica McGregor
  • Janet Pilkington
  • D.J. Rawlinson
  • Brian Watson

The issue / The problem
  • Medicare Reimbursement and its impact on CRNA

Brief Description and History
  • Medicare was established in 1965 with the
    enactment of Medicare and Medicaid legislation.
  • Originated as a health insurance program for
    the elderly paid for by Social Security Taxes.
  • Initially only provided insurance services for
    physician's and hospitalization. Now provides
    reimbursement for other healthcare providers to
    include CRNAs.

History (cont.)
  • 1976 AANA sought to receive direct
    reimbursement from Medicare.
  • 1983 Prospective Payment System was devised to
    contain hospital cost and allowed many outpatient
    procedures to be reimbursed.

History (Cont)
  • The Omnibus Reconciliation Act of 1987 required
    Medicare to implement a separate payment within
    the professional services sector for CRNA
  • Went into effect January 1st, 1989.
  • Prior to 1989, anesthesia reimbursement was
    limited to the services provided by a physician.
  • Medicare B, is the division responsible for
    CRNA reimbursement.
  • Prior to this act, CRNAs were reimbursed by
    Medicare Part A, which is the division
    responsible for hospital or institutional

Divisions of Medicare
  • Medicare Part A
  • - Payment for hospitals and ambulatory care
    facilities under Medicare.
  • - Requires CRNAs to work under the direct
    supervision of MDAs as a condition for
    reimbursement from Medicare.

Divisions of Medicare
  • Medicare Part B
  • - CRNA reimbursement.
  • - Payment for Medical direction and Medical
    supervision. ( Seven conditions of TEFRA must be

CRNA Medicare Billing Requirements
Only a Certified nurse anesthetist can
bill Medicare directly. (140.1.2 of the
Medicare Claims Manual) What does Medicare
require to bill for services? 1. Certification 2.
Recertification - Req. by AANA, assumed complete
by CMS 3. NPI (National Provider Identifier)
  • Today, reimbursement for CRNA services is many
    times ignored, overlooked, or assumed, all of
    which can result in a negative economic impact
    upon CRNAs within the healthcare marketplace.
    Todays healthcare spending is highly
    scrutinized therefore, no reimbursement
    opportunities can be left untapped, including
    those present in the system for the services of
    CRNAs. The future of the profession relies on
    the ability of CRNAs to accurately understand
    the healthcare marketplace. CRNAs must be able
    to identify their worth, understand the
    reimbursement process, and assist their employer
    or secure for themselves through private practice
    the proper portion of todays healthcare dollar
    that is due for the services they provide.

Medicare FACTS
  • CRNAs first nonphysician provider to be directly
  • reimbursed by Medicare Part B
  • Approx. 27 million anesthetics are provided by
  • CRNAs in the U.S. annually
  • Medicare reimburses anesthesia 2.4bn / yr
  • 1.7bn for anesthesiology
  • 657mn for nurse anesthesia
  • Up 25 from 2005 level of 1.9bn
  • CMS, 2007 PFS final rule CMS-1321-FC
    CMS-1317-F, 11/1/2006

Issue related to the practice standards /
  • Medicare uses the TEFRA conditions simply to
    determine if an anesthesiologist has been
    adequately involved in the administration of an
    anesthetic to justify paying the

Issue related to the practice standards /
guidelines (cont.)
  • Medicare has no requirement of anesthesiologist
    supervision and will reimburse CRNAs who are not
    supervised by any physician if they meet the
    appropriate requirements.
  • Due to the seven conditions of TEFRA, five
    Standards of Practice for the nurse anesthetist
    apply to Medicare reimbursement.

1. Preanesthetic evaluation of the patient
  • Performing and documenting a pre-anesthetic
    assessment and evaluation of the patient,
    including requesting consultations and diagnostic
  • Selecting, obtaining, ordering, or administering
    pre-anesthetic medications and fluids
  • Obtaining informed consent for anesthesia

2. Prescription of the anesthesia plan
  • Developing and implementing an anesthetic plan

3. Personal participation in the most demanding
procedures in this plan, especially those of
induction and emergence
  • Developing and implementing an anesthetic plan
  • Selecting and initiating the planned anesthetic
    technique which may include general, regional,
    and local anesthesia and intravenous sedation
  • Managing emergence and recovery from anesthesia
    by selecting, obtaining, ordering, or
    administering medications, fluids, or ventilatory
    support in order to maintain homeostasis, to
    provide relief from pain and anesthesia side
    effects, or to prevent or manage complications.

4. Following the course of anesthesia
administration at frequent intervals
  • Selecting, obtaining, or administering the
    anesthetics, adjuvant drugs, accessory drugs, and
    fluids necessary to manage the anesthetic, to
    maintain the patient's physiologic homeostasis,
    and to correct abnormal responses to the
    anesthesia or surgery

5. Ensure all procedures not personally performed
are performed by a qualified individual
  • The Standard of Practice that matches that would
  • All eleven Standards apply - because the CRNA is
    performing the anesthesia

6. Remain physically available for the immediate
diagnosis and treatment of emergencies
  • Responding to emergency situations by providing
    airway management, administration of emergency
    fluids or drugs, or using basic or advanced
    cardiac life support techniques
  • Selecting, obtaining, or administering the
    anesthetics, adjuvant drugs, accessory drugs, and
    fluids necessary to manage the anesthetic, to
    maintain the patient's physiologic homeostasis,
    and to correct abnormal responses to the
    anesthesia or surgery

7. Providing indicated postanesthesia care
  • Releasing or discharging patients from a
    post-anesthesia care area, and providing
    post-anesthesia follow-up evaluation and care
    related to anesthesia side effects or

Plan of Action
As long as there is government there will always
be a need for a plan of action. - Gary Boutwell
July 11,2007
Increase funding for education
  • In 2006 the educational fund was 3 million.
  • In 2008 our plan is to increase nurse
    anesthesia educational funding to 4 million
    which will provide more nurse anesthesia
    educational programs and increase grants which
  • support existing programs by escalating
  • Supporting more graduates to practice in
    medically underserved areas.

Change Teaching Rules!
  • It is fundamental that Medicare treat nurse
    anesthetists and anesthesiologists the same to
    insure educational equal opportunity
  • Equality in teaching anesthesiologists, nurse
    anesthetists, residents and student
  • Medicare cuts in pay discouragement in
    providing educational services.

How Does This Funding Help?
  • Grants help establish, strengthen CRNA
  • educational programs
  • Traineeships provide some funding for
  • students
  • 105 Accredited Nurse Anesthesia programs
  • Total CRNA educational funding --
  • Over 2,000 graduates in 2006, more than
  • since 2000

Past Actions
  • Take Action - It has been proven effective in the
  • HR 3617
  • S 1356
  • HR 6111
  • Results CRNAs are treated as equal healthcare

Medicare Agency Final rule provisions of interest
to CRNAs
  • Finalizes 13.7 Cut in 2007 Part B Anesthesia
    Payment No Change in Anesthesia Teaching Rules
  • There is no change in the Medicare anesthesia
    payment teaching rules in the final rule
  • Legislation introduced in Congress, the "Medicare
    Academic Anesthesiology and CRNA Payment
    Improvement Act" (HR 6184), would fix problems in
    the Medicare anesthesia payment teaching rules
    for both CRNAs and anesthesiologists. This
    legislation is supported by AANA.
  • CMS is applying changes in evaluation and
    management (E/M) code values to those anesthesia
    services where E/M constitutes a portion of the
  • CMS proposed in its proposed rule to modestly
    increase the anesthesia work value to reflect the
    increased work valued for the E/M codes where
    there were increases in the work for those E/M

Medicare Agency Final rule provisions of interest
to CRNAs (cont.)
  • CMS included two new CPT codes for anesthesia
  • The codes, 00625 and 00626 (anesthesia spine
    transthoracic with and without ventilator,
    respectively) would have base units set to 13 for
    2007. CMS accepted AMA Relative Value Update
    Committee (AMA RUC) recommendations for these
  • CMS made value changes to other CPT codes outside
    anesthesia services
  • such as for certain surgical services, which may
    impact demand for certain anesthesia services.

Act Now!
  • Thanks to action in 2006 (HR 6111) 5 of
    approximately 14 planned Medicare cuts for 2007
    was reversed.
  • This relief is only temporary (last for 1 year).
  • Without congress action and HR6111 the 2007
    anesthesia conversion factor would have decreased
    from 17.76 (2006) to 15.33 not experienced
    since before 1992.
  • Without further action cuts will resume in 2008
    and so on, could be as much as 40 by 2012.
  • We need a long term solution CMS will continue
    to assess and call for budget adjustments.

Get involved!
  • Maintain AANA active membership
  • Support the AANA monetarily
  • Communicate with Congress about these extreme
    cuts, using AANA online eAdvocacy,
  • Remember to note effects on patients access to
    healthcare services
  • Meetings with legislators in local communities-
  • Recruit CRNAs to support AANA
  • Get to know the AANA, stay informed, stay in
    touch with AANA DC
  • Get to know your legislatures- they can influence
    every aspect of your job, particularly your

Why is it important?
  • How will anesthesia professionals, anesthesia
    groups, hospitals and offices deal with cuts in
    anesthesia reimbursement per-service?
  • Answer?
  • Two fundamental choices increase revenues, or
    decrease costs.
  • Majority of CRNAs assign their billing rights to
    an employing group, hospital, or facility
  • CRNAs should learn and know their own economic
    value in the practice setting the revenues a
    CRNAs work produces.

Do you know your worth?
  • Medicare Anesthesia Economic Value Calculator

U.S. Averages 100 Medicare /Sample Personal Figures
A Medicare 2006 average anesthesia CF 17.77 / 17.77
B Medicare 2007 average anesthesia CF (est.) 16.23 / 16.23
C Average units / case 12 / 12
D Average cases / year 900 / 900
E Fraction of cases that are Medicare 0.35 / 1.00
X CRNAs' Medicare practice economic value, 2006 67,170.60 / 191,916.00 Y CRNAs' Medicare practice economic value, 2007 61,349.40 / 175,284.00
Z Impact of Medicare cuts on above values 5,821.20 / 16,632.00
How to ACT?
  • Through AANA guide legislators to introduce
    appropriate bill.
  • In our case a bill reversing Medicare cuts.
  • CRNAs act by writing there appropriate members
    of congress, to pass said bill.
  • State associations and others write letters of

ASAs actions
  • Teaching Rules - which effect reimbursement of
    students providing anesthesia (nurse anesthesia
    students and residents in anesthesia).
  • Introducing bills specific to anesthesiologist
    and residents.
  • HR 5246
  • HR 5348 Stark
  • S2990 Vitter
  • These bills have not been adopted

  • Meetings local, state, and federal.
  • AANA website
  • AANA News Bulletin
  • CMS website
  • Alabama Association of Nurse Anesthetist -
  • Realize AANA has a DC office.

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Proposed alternative and timetable for resolution
  • Issues for Lobbying Capitol Hill
  • Educating Legislators About CRNAs
  • Keeping Medicare Strong
  • Equity in CMS Anesthesia Teaching Rules
  • Nurse Anesthesia Education Funding

Get involved NOW !!
  • Attend the 2007 AANA midyear assembly in Denver,
  • Let your voice be heard!!
  • As Washington looks for answers to healthcare
    financing, access and quality issues CRNAs must
    leave a strong, positive impression with
    legislators for our issues the others to come.

Current status of Medicare problem
  • The Washington Environment
  • In Government
  • New Democratic Congress
  • Jockeying to succeed President Bush
  • In Policy
  • Budget running enormous deficits,
  • short- and long-term
  • Focus War, healthcare, budgets

Current status of Medicare problem
  • The Washington Environment
  • In healthcare
  • the publics second-highest issue interest
  • Fiscal challenges Part B cuts
  • Pay-for-performance / quality
  • reporting / health I.T.
  • Insurance reforms
  • Singlepayor, employer mandate,
  • tax incentives
  • Obstacles to big initiatives

Who Matters in Government?
  • The people who make the rules
  • The people who enforce the rules
  • The people who pay for things

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Why Do They Matter to CRNAs?
  • Congress Committees of Jurisdiction
  • Medicare-writing House Ways Means,
  • Senate Finance, House Energy Commerce
  • Funding House and Senate Appropriations
  • Education Other Health House Energy
  • Commerce, Senate Health Education Labor

CRNAs Make A Difference
  • CRNAs are ensuring clinical excellence
  • Accreditation, cert, recert, practice
  • CRNAs develop expertise in policy areas
  • Meetings, training, committees, advisory
  • We have gotten organized
  • We are applying what we know in Washinton D.C.
  • Today!

Medicare Payment Trends
  • 2004 1.5
  • 2005 1.5
  • 2006 No change
  • 2007 8 (not -14 as originally proposed)
  • 2008 - 10
  • 2009-2012 - 25-30

Medicare Payment Trends
  • Cuts will come unless Congress acts
  • Medicare payment drives other payments
  • Government programs like Medicaid
  • Federal employee benefits (FEHBP,
  • TRICARE/Champus)
  • Unlike in 2007, all Part B providers are in
  • the same boat

CRNA Education Message
  • Congress should request
  • 4 million for Nurse Anesthesia Education
  • 76 million for advanced education nursing
  • 200 million in total for nurse education

The BIG Message
  • Medicare anesthesia payment got cut in 2007
  • Future Medicare payment cuts of up to 35-40
  • in five years would destroy the Medicare
  • program for our seniors
  • Congress should enact legislation to reverse
  • Medicare Part B physician fee schedule cuts
  • that are scheduled for 2008 and beyond.
  • Continue to include CRNAs in the development
  • of pay-for-performance quality measures

You Make the Difference!
  • For Our Patients, Practice and Profession
  • Your DC Office
  • Frank Purcell, Sr Dir, Federal
  • Govt Affairs
  • Brian R. Bullard, Assoc Dir,
  • Federal Govt Affairs
  • Pamela Kirby, Assoc Dir, Federal
  • Regulatory Payment Policy
  • Shari Dexter, Political Affairs Mgr
  • Candi Richardson, Senior
  • Administrative Assistant

  • 1. What act required Medicare to implement a
    separate payment within the professional services
    sector for CRNA reimbursement? What year did it
    go into affect?
  • 2. What part of Medicare is the division
    responsible for CRNA reimbursement?
  • 3. True/False    The 7 conditions of TEFRA apply
    to CRNA reimbursement and directly correlate with
    most of the CRNA Scope of Practice.
  • True/False    In order for the CRNA to be
    reimbursed by Medicare, he must be supervised by
    a physician.

  • 4. What governmental group/committee is
    established for approving or denying federal
    program funding?
  • 5. Why does the educational fund for nurse
    anesthesia need to be increased from 3 million to
    4 million?
  • 6. How will anesthesia professionals, anesthesia
    groups, hospitals, and offices deal with cuts in
    anesthesia reimbursement per-service?

  • 1. Foster SD, Faut-Callahan M. A professional
    Study and Resource Guide for the CRNA. Park
    Ridge, IL AANA Publishing Inc 2001 180-181,
    288, 358.
  • 2. Culpepper TL. History of Nurse Anesthesia,
    PowerPoint / Lecture. Samford University, Ida V.
    Moffett School of Nursing, Department of Nurse
    Anesthesia June 12, 2007 pg.4, slide 3.
  • 3. Nagelhout JJ, Zaglaniczny KL. Nurse
    Anesthesia. 3rd ed. Philadelphia, PA Saunders
    2005 1249-1263.
  • 4. AANA Professional Manual for CRNAs

  • 5. Scope and Standards for Nurse Anesthesia
    Practice. Park Ridge, III American Association
    of Nurse Anesthetists 1996.
  • 6. American Association of Nurse Anesthetists -
    Office of Federal Government Affairs. Apr. 2007.
  • 7. American Association of Nurse Anesthetists -
    Office of Federal Government Affairs. Mar. 2007.
  • 8. Blumenreich GA. Standards of Care and the ASA
    Medical Direction Statement.  AANA Journal, Vol.
    72 (No. 2) 2004.

  • 9. Purcell, FJ. Government Relationship and
    Federal Issues. AANA Mid-year Assembly PowerPoint
    Presentation. May-June 2007.
    Accessed and permission granted July 20, 2007.
  • 10. Purcell, FJ. Analysis of Federal Issues.
    AANA Mid-year Assembly PowerPoint Presentation.
    May-June 2007. Accessed and
    permission granted July 20, 2007.
  • 11. Purcell, FJ. CRNAdvocacy 101 How CRNAs
    Action Affects CRNAs Patients, Practice
    Profession. AANA Mid-year Assembly PowerPoint
    Presentation. May-June 2007.
    Accessed and permission granted July 20, 2007.

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