Understand the 2021 changes in Emergency Medicine

Emergency medicine groups have faced a lot this year. It includes a new federal ban on surprise medical billing, updates to the Medicare reimbursement formula, changes to the CMS MIPS program, and new billable services. This article summarizes the changes provided by the experts.

 Federal Ban on Surprise Medical Billing in Emergency Medicine:

  • During the end of 2020, Congress had passed a major omnibus bill that included a federal ban on surprise medical billing (SMB) called the “No Surprises Act.”
  • This legislation resulted after years of discussion with both physician groups and insurance companies.
  • Both the sides agreed with the idea that patients should be removed from what is essentially a payment dispute. Moreover there was a lot of debate on how to approach this on such a large scale and with concern for unanticipated consequences.
  • “The federal ban on surprise billing was long overdue,” explains Dr. Andrea Brault, President and CEO of Brault Practice Solutions and advocate for independent physician practices. “Many states have already moved in this direction, but these state laws didn’t always address the ERISA plans that now make up the majority of individual, employer-based health plans. So, the result was public frustration and more confusion”.
  • Brault also explains that it was really up to federal lawmakers to establish a uniform set of rules that would address the ERISA plans and also address those states without comprehensive patient protections for out-of-network care.
  • She apparently explained about emergency medicine and how the medical provider community spent a lot of time educating lawmakers about the potential effects of these new rules. In some areas, they were able to impart some reasonable guidance.
  • However, Dr. Brault explains that the new federal SMB law also includes some requirements that will create new challenges for those in emergency medicine. For example:
  1. Requiring timely responses from insurers (must pay or deny within 30 days)
  2. Creating an Independent Dispute Resolution process, with no minimum threshold to access mediation (including high-volume, low-dollar disputes that make up the majority of ED claims)
  3. Allowing similar claims to be batched for added efficiency
  4. Requiring mediators to consider prior contracted rates, and prohibiting them from comparing those rates to public payer rates (which are designed to be lower than commercial rates)
  5. Limits on claim batching (only within a 30-day period)
  6. A 90-day “cooling off period” before a new dispute can be made (which will significantly delay timely, appropriate payment on the majority of disputed claims)
  7. Early language that indicates batching will only be allowed for same Provider or same Facility (despite ED services being billed by TINs)
  8. Requiring mediators to consider the plan’s median in-network rate, but prohibiting them from comparing those rates to billed charges or usual and customary rates.
  9. “We now have the rest of the year to prepare for these changes, before the new law goes into effect in 2022,” explains Dr. Brault. “Hospital-based physician groups should be reaching out to their advocacy organizations for opportunities to participate in the rule-making or administrative phase as they are the most likely to be impacted by this Act.  The negative or positive impacts of this new law will depend on the details to be hammered out in 2021”.

An increase in RVUs for emergency medicine E/M codes:

  • In 2021, emergency medicine providers also saw changes related to the Final Rule of the Medicare Physician Fee Schedule (PFS) that includes an increase in Relative Value Units (RVUs) for Emergency Department (ED) evaluation and management (E/M) codes 99283-99285.
  • “This is an important update for emergency groups to be aware of,” explains Dr. Brault. “This increase in RVUs applies directly to Medicare reimbursement, but it’s worth noting that many commercial payers also consider these values in their formulas for reimbursement. So, keep an eye on your payments/RVU (by Payer) and be aware of the things that can impact this reimbursement.”
  • In order to maximize the reimbursements, it’s recommended for physician groups to rely on statistical data such as group and provider-level metrics.
  • It’s a common best practice to look at RVU data by diagnostic group, and then compare across each healthcare provider.
  • It could also help healthcare professional groups to identify outliers on their team who may need additional help with documentation of their medical decision making (MDM).

Medicare Conversion Factor that determines total payment:

  • The Conversion Factor (CF) is a multiplier used to calculate total Medicare reimbursement for covered services. The Medicare reimbursement formula is as follows: Total Payment = RVUs (x) Conversion Factor (x) Geographic Adjustment. And, per budget neutrality rules, CMS is required to adjust the Medicare CF based on total expected payments.
  • In 2021, the PFS Final Rule called for a steep decrease to the Conversion Factor from $36.09 in 2020 to $32.41 in 2021. It was a correction of -10.2 percent, which would have been driven by the increased RVUs for office based CPTs and new proposed G-codes.
  • The Omnibus Bill that passed at the end of 2020 addressed the decrease through several actions – including a 3.75% increase to all Medicare payments, an extension of the 2 percent sequestration pause through March 31,2021, and a delay in the implementation of the G2211 primary care add-on complexity code.
  • “The delay in the implementation of the add-on complexity code caused a re-calculation of the conversion factor,” explains Dr. Brault. “By adding billions of dollars back onto the neutrality table CMS was able to reset the conversion factor to a more manageable level at $34.89.”
  • “The big takeaway here is that emergency providers will see a large increase for code 99283,” explains Dr. Brault. “However, since the beginning of the pandemic, patients with this level of injury or illness were able to obtain acute care in places other than the emergency department and this trend is predicted to continue.  So, it’s likely that providers will only realize a slight increase in reimbursement as the majority of Medicare patients are expected to be 99284 and 99285 (or higher),” explains Dr. Brault.

There might be many changes arriving each year. But its utmost purpose is to deal with accuracy and understanding. Choose to go for outsourcing companies for further queries and details related to billing and coding.

Medicare Physician Fee Schedule Updates 2022

The Medicare Physician Fee Schedule released by the CMS for emergency physicians includes certain critical changes that the provider office should note as the changed rules will directly impact the revenue flow of the organization. Here are some of the major points to consider when building a strategy for 2022:

  • The conversion factor for 2022 is $33.60, as opposed to the conversion factor of 2021, $34.89.The decrease in the conversion factor will negatively affect the physician’s income and the revenue flow of the practice.
  • The 4% Medicare cuts according to the Statutory Pay-As-You-Go (PAYGO) Act will further decrease the Medicare income of the practice. Given the effective clauses of the Act, it is crucial for the billing team to process clean claims and decrease the denial rates to keep the revenue integrity strong.
  • Split or Shared E/M visits have also undergone certain policy changes in 2022. The updated definition of the split and shared E/M visits read that at least the physician or NPP needs to be present in-person during the service at the facility.
  • Under the shared E/M visit section, the provider who renders the “substantive portion” of the service will be allowed to bill. The substantive portion of the bill will depend on three components, namely, history, exam, or medical decision making. Or it can also be based on more than half of the total time spent. The definition will only include more than half of the total time spent for critical care services.
  • While the three components are valid for 2022, the substantive portion will only be more than half of the total time spent from 2023 onwards.
  • The CMS is allowing split or shared services to be reported both for new and established patients. It will also be valid for initial visits, subsequent visits, and prolonged services.
  • The billing team needs to use a modifier in the claim to ensure the integrity of the split or shared services. The medical records must also contain the identification of the two professionals who are performing the medical procedures with the signature of the provider ensuring the “substantive” part of the service.
  • The providers cannot count separately reported services under the same split service segment. They also cannot include the teaching or discussion time spent when handling the patient.

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