NEW: Latest MRS – MA Managed Care Report issued on 7/15/2011
BCBSMA Multiple Procedure Payment Reduction (MPPR), BCBSMA Conversion Factor Changes, Tufts Health Plan MPPR policy etc.
MANAGED CARE COMMITTEE REPORT 2010-11
As in recent years, 2010 has been an active and eventful year. As the interest in the escalating cost of health care intensifies, the focus of attention is pointed squarely on the high cost of imaging.
The ultimate impact on imaging of the passage of the Patient Protection and Affordable Care Act (PPACA) along with the Health Care and Education Reconciliation Act (HCERA) in 2010 is still uncertain. There have, however, been a number of CMS changes this year.
As of July 2010, the reduction for the technical component of contiguous body areas imaging for CT, MRI and ultrasound was increased from 25% to 50%. This 50% multiple procedure payment reduction (MPPR) will be expanded in 2011 and no longer be confined to contiguous body part imaging and will cross modalities (for example, ultrasound and CT done on the same patient on the same day). The ACR has vigorously opposed this expansion but to no avail.
The equipment utilization rate will be increased from 50% to 75% as of January 2011. This will impact the technical component of high tech outpatient office imaging and, as an adjunct to the DRA, will almost certainly serve to drive imaging from the office based setting back into the hospitals. Initially, the proposal from CMS was to increase this to 90% but input from organizations such as the ACR served to lower this level to 75%.
Three new CPT codes for CT abdomen and pelvis (74176, 74177, and 74178) have been created as of January 2011. This is the result of CMS review of codes that are frequently billed together and therefore assumed to be misvalued. The RVUs assigned to these new codes are not the sum of the individual codes but are discounted.
The in-office ancillary services exception for self referral of imaging has a new requirement as part of the PPACA. Physicians referring a patient to a site in which they have an ownership interest are now required to disclose this to the patient and, as of 2011, will be required to provide a list of 5 other imaging providers in their geographic area as alternatives sites for imaging.
2010 was a tense year with respect to the Medicare Physician Fee Schedule. A 21% fee cut was avoided 4 times during 2010 and ultimately a 24.9% cut for 2011 was averted with an extension of the existing fee schedule through 2011. The ultimate solution to the SGR problem remains unaddressed and we will doubtless be facing similar issues to those addressed with short term fixes again at the end of 2011.
Massachusetts is continuing the debate on global payments. This was the recommendation of the Special Commission on the Health Care Payment System of 2009 and this appeared to be shelved for the foreseeable future. At the direction of JudyAnn Bigby, Secretary of Health and Human Services, a sub-committee of the Health Care Quality and Cost Council has recently been established (with minimal physician representation) to explore moving 95% of Massachusetts health care to global payments within the next 5 years. The recommendations of this council will be presented to the legislature next year and possibly voted upon by the fall of 2011. The angst that this is creating amongst Massachusetts physicians is dramatic and the MRS in conjunction with the ACR will do everything that it can to have some influence on the outcome of this council.
The decision by BCBSMA to deny payments for 3D reconstruction for advanced imaging as of December 2009 has been an ongoing issue in 2010. The MRS, with the assistance of ACR legal counsel, has filed a complaint with the facilitator of the BCBS class action lawsuit settlement against the institution of this policy. At this point in time, the outcome of this filing is unresolved.
BCBSMA instituted a multiple procedure reduction payment policy as of 15 August, 2010. This policy implements a 50% reduction for multiple procedures (CT, MRI, and USG) but is not a contiguous body parts policy. In addition, this policy impacts both the technical component (TC) and professional component (PC) of imaging. The MRS vigorously opposed the implementation of this policy and met with BCBSMA twice to discuss the lack of rationale for including the PC. BCBSMA refused to alter their position and implemented this policy as planned. The MRS, once again with assistance from ACR legal counsel, has filed a complaint with the facilitator of the BCBS class action lawsuit settlement. This is ongoing at this point in time.
As can be extrapolated from the summary of Federal and State changes that either have occurred or are projected to occur, 2010 was a tumultuous year. One can only assume that the future will be very similar and we, at the MRS, will do our best to protect the rights of the radiology community of Massachusetts.
Philip A. Rogoff, MD, FACR