The Centers for Medicare and Medicaid Services (CMS) have released their final payment rule for Medicare programs, which will affect care and coverage for patients insured through Medicare. These rulings will go into effect in 2019, impacting practices for the year to come. With regards to anesthesia practice management, the final payment rule will institute policies that may impact pricing, reimbursement, and case management.
Medicare management of outpatient treatment is set to experience many changes in 2019. The Outpatient Prospective Payment System (OPPS), the central pricing mechanism for all outpatient procedures, is scheduled to undergo a rate increase of approximately 1.25%, as calculated by annual inflation, productivity, and service value additions. This new rate will extend to all CMS “Centers of Excellence”, as well as all Medicare providers that oversee outpatient surgical treatments. The updated rules are also provisioned to decrease the percent reimbursement allocated for out-of-network providers. Per this update, outpatient surgeries performed by out-of-network providers will be reimbursed at 40% of the national Medicare rate, creating a significant financial disadvantage for choosing out-of-network providers. Such an action can be attributed to the push for a more segmented healthcare market where patients select providers based on their coverage.
Beyond changes in reimbursement related to outpatient procedures, the new payment rule also expands coverage. In 2019, specific cardiology procedures will be added to the coverage list, including cardiac catheterization. Anesthesiologists that work closely with cardiologists, interventional cardiologists, and cardiac surgeons should take note of such coverage expansions. In the orthopedic sector, the Current Procedural Terminology (CPT) code designation for anesthesia on open procedures such as knee joint replacement and total joint arthroplasty was removed from the inpatient-only designation. This change in designation means that certain open procedures can now be reimbursed in both inpatient or outpatient settings. This change also aligns with technological advances in musculoskeletal care, such as image-guided surgery, which have rendered feasible procedures that were previously only accessible in inpatient settings. Anesthesia providers that focus on orthopedics should be aware of this change when considering the transition to including flexible setting procedures in their practice.
For anesthesia and pain practices that are also involved in the management of drug supply and disbursal, the final payments rule has distinguished payments between opioid and non-opioid pain medications in an initiative to more closely monitor the opioid landscape in the United States. By making this distinction, the use of opioid-based anesthetics will become separated from the general supply of anesthetics, encouraging anesthesiologists and pain management physicians to conduct a thorough assessment of the costs and benefits of each before administering or prescribing them to patients.
In summary, the CMS final payment rule for Medicare programs in 2019 instates new policies that may influence anesthesiologists, certified registered nurse anesthetists (CRNAs), and anesthesia practice managers through changes in pricing, reimbursement, access, and coverage. By maintaining a comprehensive understanding of these new Medicare policies, anesthesia practices can ensure that they are continually improving the quality of healthcare delivery by more thoughtfully serving patients.
- Stewart A. “What ASC anesthesia groups should know about the 2019 final payment rule: 6 insights.” Becker’s ASC Review. 2018 Nov. https://www.beckersasc.com /anesthesia/what-asc-anesthesia-groups-should-know-about-the-2019-final-payment-rule-6-insights.html
- Ellison A. “CMS’ proposed outpatient payment rule for 2019: 10 things to know.” Becker’s ASC Review. 2018 July. https://www.beckershospitalreview.com /finance/cms-proposed-outpatient-payment-rule-for-2019-10-things-to-know.html
- CMS. “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019.” Centers for Medicare & Medicaid Services. 2018 Nov. https://www.cms.gov/newsroom/fact-sheets.