Providers want the Centers for Medicare and Medicaid Services to change an upcoming policy on reimbursement for hospital visits when both physicians and non-physician providers see patients.
CMS recently tariff for doctors proposes deferring until 2024 a requirement that time spent with a patient would determine which provider could charge for a visit. CMS originally planned to launch the policy next January.
Healthcare trade associations welcomed the delay but urged CMS to use the additional time to find an alternative policy that would allow billing based on which provider spent the most time with a patient or who guided medical decision-making . Vendors fear the directive could result in a 15% wage cut for facilities.
“We continue to have significant concerns about this policy and therefore support CMS’ proposal to delay its implementation. We urge the agency to take advantage of this delay to re-examine this policy, including by working with stakeholders to develop an alternative proposal for billing for shared or joint visits,” the American Hospital Association wrote in a comment letter to CMS.
Medicare pays more for medical services than other progressive providers, such as physician assistants and nurses, provide. While physicians receive full Medicare reimbursement for assessment and administrative visits, non-physicians typically receive 85% of the Medicare rate.
In a practice setting, healthcare providers can use incident-to billing and bill for a physician visit when a non-physician healthcare provider sees a patient. However, in hospitals and other facilities, incident-to-billing does not apply.
Until last year, CMS relied on guides to manage billing for shared or joint visits to a facility, allowing physicians to bill for joint assessment and administrative visits when the physician provided a significant portion of the service.
But when the Trump administration left office in January 2021, the Department of Health and Human Services became issued a draft regulation aimed at addressing policies set outside the rules for posting and commenting, which brought the policy on joint visits to the fore. CMS withdrew the billing guideline for joint visits in May 2021 and announced that it would return to the guideline in rulemaking.
CMS’ Fee schedule for doctors 2022 expanded when providers could charge for joint visits, codified a definition for the visits and, most importantly, used the time to identify which provider performed the substantial part of a visit.
Providers expressed concern about the directive in comments on the 2022 fee schedule. The Mayo Clinic described time tracking as “extremely problematic” in a comment letter sent to CMS last year.
“What may have been considered the doctor who spent a ‘significant’ time in the [evaluation and management] visit may change if another [non-physician practitioner] of the same specialty sees the patient later in the day. That [non-physician practitioner] may not know how much time each provider spent with the patient, especially if not all providers document the time,” the Mayo Clinic wrote.
More than 40 health professional associations sent another letter to CMS in March, asking the agency to propose a common visiting policy based on both decision-making and time. The policy adopted this year is disruptive team-oriented supportwrote the groups.
Although CMS finalized the changes last year, in July the agency proposed moving the policy on using time to determine billing. According to CMS, an extra year would give providers time to get used to other changes in how billing is assessed and managed. The delay also gives CMS an opportunity to gather more feedback and find out if the policy needs adjusting, the agency wrote in its proposed rule.
In comments, providers welcomed the delay in the recent fee schedule proposal, but continued to raise concerns that time could be used to decide which provider can bill. The American Association of Nurse Practitioners said the policy could result in more visits from non-doctors being billed, which could result in a significant pay cut.
“Billing under a doctor versus a nurse allows reimbursement at a 15% higher rate than billing through an NP. This is an acute problem in rural and underserved areas, where systems and agencies with limited financial resources may not be able to sustain a 15% cut in payments despite the NP providing the same level of service as their medical counterpart,” wrote the organization to CMS.
Providers asked regulators to allow both time and medical decisions to determine which doctor will perform the essential part of a visit.
“Time is not necessarily the essence of patient care. Medical decision making is a critical element in managing patient care; however, it does not usually require the most time. Physicians are compensated for their ability to synthesize complex medical problems and administer appropriate treatments,” the Association of American Medical Colleges wrote in a letter.
Emily Cook and Caroline Reignley, both partners at law firm McDermott Will & Emery, expect CMS to complete the policy delay. But while Cook said she wouldn’t be surprised if the agency allowed billing based on medical decisions next year, Reignley is more skeptical. “CMS likes objective measures. I think time is more objective — medical decision making is getting muddy,” Reignley said.