Suspicions arise that HCFA is using reduced RVUs to downgrade payments
January 1, 2000 3 minutes read
Suspicions arise that HCFA is using reduced RVUs to downgrade payments
New system hits critical care docs especially hard
Despite a number of positive payment-related provisions, a growing number of physician specialty groups are raising questions and eyebrows about several easily overlooked changes that lower reimbursement levels contained in the recently published Medi care physician fee schedule for 2000. That includes what some say looks like a backdoor attempt to reduce physician payments by whittling away at the worth of the relative work value units used to set fee scales for specific codes.
Work value units are used to determine 54% of any particular medical service’s payment value and are a major component of the newly installed relative value unit (RVU) system used to calculate Medicare physician payments.
Since 1991, the American Medical Association/Specialty Society RVU Update Committee, also called "the RUC," has been charged with studying and recommending work relative values for consideration by the Health Care Financing Administration (HCFA) when it assigns new and revised payment codes.
During this relatively short working relationship, HCFA has accepted 90% to 95% of the RUC’s recommendations. For the 2000 physician fee schedule, however, HCFA rejected and then reduced 20 of the RUC’s 65 unanimous work value recommendations — a 30% turndown rate. Hardest hit were codes relating to services and procedures provided to critically ill patients.
Moreover, HCFA has indicated that it plans to track how often codes for critical conditions are used, implying that further reductions might occur in RVU values if utilization rises. That move has alarmed a number of physician lobbies.
If that informal practice becomes formal agency policy, many specialties are worried HCFA will expand the monitoring mandate from critical care to a range of other kinds of codes.
"From our perspective, it is an absolutely inappropriate policy that is sort of hidden in the rule," says Katie Orrico, director of the Wash ing ton, DC, office of the American Association of Neurological Surgeons. "This has potentially dangerous implications for other codes in the fee schedule which could affect any number of specialties."
"This is little more than regulatory blackmail," says George Sample, MD, a surgical intensivist at the Washington (DC) Hospital Center.
While the total dollar impact of the 2000 changes is not yet known, the American Medical Association estimates that HCFA’s slashing of the RUC-recommended new work value RVUs for just two often-used codes will shrink Medicare payment for physician services by a whopping $27.6 million, annually.
The two codes are:
• 99291 (critical care, first hour). RUC recommended a 4.00 work RVU. HCFA approved a 3.60 work RVU.
• 99292 (critical care, additional 30 minutes). RUC recommended a 2.00 work RVU. HCFA approved a 1.80 work RVU.
Age drives the change
What is setting up this conflict? With the population starting to age at an increasingly faster rate, many physicians say critical care is being underreimbursed by Medicare. Because of that demographic driver, HCFA knows it has to keep a tight lid on the cost of services doctors render to critically ill patients if it is going to stop Medicare from spurring increasingly larger lakes of red ink.
With more than 7,000 different CPT codes currently in use, some providers are afraid if HCFA continues to reject otherwise well-considered RUC recommendations, it will mean a financial version of slow death by 1,000 tiny (and some not so tiny) cuts in Medicare RVU levels.
What especially worries many provider groups is that the action came without the usual advance warning from HCFA that a major change was in the works. "Despite the fact that we were working in good faith, HCFA arbitrarily and unilaterally decreased the relative value units," says Sample.
Look for plenty of behind-the-scenes maneuvering in coming months as physician interests and administration regulators battle this one out.
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