CMS reduces Colonoscopy Reimbursement in 2018

The 2018 Medicare Physician Fee Schedule reduces the base unit value for screening colonoscopy from 5 to 3, this represents a 40% reduction in base units for the procedures that translates into an estimated 28% reduction in reimbursement, based on an average of 7.2 units billed.  CPT codes 00740 (anesthesia for upper GI procedures) and 00810 (anesthesia for lower GI procedures) have been replaced with a series of five new codes to distinguish different types of procedures.  We will be calculating the anticipated financial impact associated with the changes for each of our clients and communicating this for budgeting and planning purposes. 

Discounting Can Cause Compliance Issues for Anesthesia Group

Anesthesiologists know professional courtesy, co-payment waivers and discounts for cash payments could cause compliance issues. You need to know the nuances to three situations; Professional Courtesy, Waiver of Co-pays & Cash Pre-payment versus Insurance, to avoid compliance issues. 

1. Professional courtesy. It is legal to provide courtesy to physicians in the community, other healthcare providers, and their staff, generally speaking. However, it becomes illegal is when courtesy targets physicians or people who are in a position to refer federally-insured patients to the practice. This is a Stark violation. Suggestion: Offer the courtesy discount to all physicians on the medical staff and the CRNAs & AAs that practice at your contracted facilities.

2. Waiving co-pays or accepting “insurance only” as payment. Patient co-pay waivers are generally illegal and certain states have deemed “insurance only” billing as fraud. There is however, one limited exception to the prohibition of co-pay waivers — a waiver based on demonstrated financial hardship. Practices must determine a process in terms of what patients need to provide to qualify for this exemption. Suggestion: Follow the hospitals hardship policy, if the hospital approves the patient discount the same level. You can discount the patients balance after they have received a single statement after insurance has made payment without violating any contacts.

3. Discounts for cash payment. The practice of bypassing insurance is legal, but anesthesiologists need to check whether undercutting their own negotiated rates violates any of their health plan contracts. Suggestion: Only allow cash pre-payment prior to surgery.