The Centers for Medicare and Medicaid Services (CMS) have officially released their final payment rule for Medicare policies, which will impact coverage and care for Medicare-serving institutions. The new payment rules will be implemented in 2019, affecting medical practices for the coming year. With regards to anesthesia practice management, the final payment rule calls for the implementation of policies that may impact pricing, reimbursement, and case management.
Management of outpatient treatment is set to change in 2019 as per the new CMS payment rules. The Outpatient Prospective Payment System (OPPS), the central reimbursement mechanism for all outpatient operations, is scheduled to undergo a projected rate increase of 1.25%, as calculated by yearly inflation, productivity, and service value approximations. This increased rate will apply to all CMS “Centers of Excellence”, as well as all Medicare providers that administer outpatient surgical treatments. The updated rules are also scheduled to reduce the percent reimbursement allocated for out-of-network providers. Per this update, outpatient operations performed by out-of-network providers will be reimbursed at less than half of the federal Medicare rate, resulting in a marked financial penalty associated with selecting out-of-network providers. This action aligns with the movement for a more segmented healthcare market in which patients select their providers based on their coverage.
Along with changes in reimbursement related to outpatient procedures, the updated payment rule also expands coverage. In 2019, certain cardiology procedures will be added to the coverage list, including cardiac catheterization. Anesthesiologists that work in tandem with cardiologists, interventional cardiologists, and cardiac surgeons should take note of these 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, has been removed from its previous inpatient-only category. This change in designation means that certain open procedures can now be reimbursed in both inpatient and outpatient settings. This updated policy is partly in response to technological advances in musculoskeletal care, such as image-guided surgery, which have made procedures that were once restricted to the inpatient setting feasible in the outpatient setting. Anesthesia providers that focus on orthopedics and rheumatology should be aware of this change when considering the transition to including flexible setting procedures in their practice.
In addition to specialization-specific changes, the final payments rule also initiates changes in drug delivery and reimbursement, which may also become relevant to anesthesiologists and pain management practices. Specifically, the final payments rule has distinguished payments between opioid and non-opioid pain medications in response to new awareness of the opioid prescribing landscape in the United States. By making this distinction, the use of opioid-based anesthetics will be considered distinct from the broader category of general anesthetics, encouraging anesthesiologists to conduct a thorough assessment of the costs and benefits of each before prescribing them to patients.
In summary, the CMS final payment rule for Medicare programs in 2019 enacts new policies that may influence anesthesiologists, certified registered nurse anesthetists (CRNAs), and anesthesia practice managers in the coming years. By maintaining a comprehensive understanding of the new Medicare policies for pricing, reimbursement, access, and coverage, anesthesia practices can continue to thoughtfully serve their 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