From gold card programs to reimbursement cuts, physicians across several specialties have clashed with payers over 2024 due to major policy changes.
Here are six physician and payer conflicts to know from the last year:
Gastroenterology conflicts
1. Two major gastroenterology organizations criticized CMS' proposal to cut physician pay by 2.8% in its physician fee schedule for 2025. The Digestive Health Physicians Association released a statement July 16 opposing the proposal, saying it "follows years of negligible increases, freezes and a payment cut in 2024. This is unsustainable for our nation’s medical groups, physicians and other healthcare providers," the statement said. "The effects of these cuts will be exacerbated in rural and underserved areas, which continue to face significant healthcare access challenges." The American Society for Gastrointestinal Endoscopy echoed these concerns, calling on Congress to reverse the proposed cuts in a July 12 statement.
2. The American College of Gastroenterology's prior-authorization task force and the American Gastroenterological Association issued statements expressing skepticism over UnitedHealthcare's gold-card program, which went into effect Oct. 1. A number of GI procedures, including intestine imaging and GI endoscopic ultrasounds, are eligible for the new program. The program rewards contracted provider groups that "consistently adhere to evidence-based care guidelines" by allowing certain physicians to bypass the prior authorization process. While the payer promised that it was a move toward reducing prior authorizations, physicians have continued to express skepticism.
"The concept of a gold card program as it is currently proposed, only places the leverage back in the hands of the insurance carrier. This will force providers to comply with care models that are 'approved' by the carrier. If we are to champion the best interest of the patient, who ultimately is the recipient of care, then there must include accountability for cost shared by the insurance company, patient and provider," Yeshvant Navalgund, past president of the Pennsylvania Pain Society, medical director at National Bioskills Laboratories and founding member of the American Society of Regional Anesthesia Special Interests Group in Pain Management, told Becker's.
"This is achieved by cost savings incentives directed at the customer, namely the patient, and if the patient is compliant with care, the provider is conscious about the care using specialty-specific, evidence-based models and [the] insurer is incentivized to provide reimbursement when each of these criteria are met, this model may have a sustainable opportunity. For these reasons, I don’t feel the current proposed model will benefit providers or patients, he said."
Anesthesia conflicts
1. Ohio-based health insurance provider Medical Mutual plans to reduce certified registered nurse anesthetist reimbursements to 85% beginning Jan. 24. The American Association of Nurse Anesthesiology issued a statement expressing disapproval over the policy, with organization President Jan Setnor, MSN, CRNA, calling it "a blatant, dangerous and self-serving attack on CRNAs and the patients they seek to care for." This policy is in line with similar ones enacted by other insurers throughout the year.
2. Kaiser Foundation Health Plan walked back an anesthesia pay change that was implemented in Washington state in November and was unpopular among practitioners. Under the reversed plan, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options would no longer reimburse anesthesia services when submitted without the appropriate modifiers identifying who performed the service. Additionally, the plans reduced QZ services rendered by certified registered nurse anesthetists to 85% of the physician fee schedule. The move came after the AANA said in a Dec. 10 statement that the policy "discriminates against CRNAs based on their licensure because the policy does not affect any other anesthesia providers who offer the same services as CRNAs."
3. Anthem Blue Cross Blue Shield reversed a controversial anesthesia policy following the pushback from several physicians and advocacy groups. The policy update would have introduced a new reimbursement structure based on CMS physician work-time values. Claims exceeding these predetermined time limits would have been denied. Initially announced on Nov. 1, the policy would have taken effect on Feb. 1, 2025, impacting anesthesia claims across Connecticut, New York and Missouri.
Spine conflicts
1. Spine and orthopedic groups are strengthening their revenue cycle teams and clinical documentation improvement programs to stay ahead of insurance coverage policy changes. Shannon Cameron, COO of the billing operations for Harvard Medical Faculty Physicians, said her organization has started to see insurers rescind their payments, causing financial problems for physicians and practices.
"Just because you have a prior auth, it's a huge myth that it's going to get paid," said Ms. Cameron. "Diagnosis in and of itself is not enough to support that claim. That's why they're going back and asking for those medical records, which is nothing new. They've been doing that for years, but this recent tactic is huge. If you don't have the documentation in place to start, then those are going to turn into denials and you're going from payments to flipping back a year later to a denial."