Anesthesia practices expanding their endoscopy services should proceed cautiously, as payers have begun changing their reimbursement policies to limit claims, according to Anesthesia Business Consultants President and CEO Tony Mira.
Here's what you should know:
1. After CMS implemented its policy for anesthesia payment for endoscopy four years ago and other payers followed suit, there was dramatic growth in endoscopy cases among anesthesia practices from 2013 to 2017.
2. As a result of the surge, payers had to pay more for those endoscopy claims than originally budgeted.
"Many insurance plans had not predicted the growth — and the expense — of these claims, and have begun rethinking their commitment to these services, underscoring the fundamental economic reality that healthcare is a business," Mr. Mira said.
3. The volume also prompted scrutiny over the valuation of services. The American Medical Association and CMS agreed to devalue a colonoscopy from a base of 5 to a base of 3 for Medicare claims. Colonoscopy was downgraded to a base of 4 for commercial claims.
4. Payers now seem to be pre-screening patients for endoscopy anesthesia services based on medical necessity. Wellesley, Mass.-based Harvard Pilgrim was the first to implement a policy outlining specific conditions that must be met in order for a patient to receive anesthesia care for an endoscopic procedure.
5. ABC monitors denials by payer for clients for evidence of a new policy, and has found evidence other payers are developing similar guidelines intended to limit utilization.
"If you are expanding your endoscopy service, we recommend that you continue, but be sure to closely monitor your productivity and reimbursements," Mr. Mira said.