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:
Requiring timely responses from insurers (must pay or deny within 30 days)
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)
Allowing similar claims to be batched for added efficiency
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)
Limits on claim batching (only within a 30-day period)
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)
Early language that indicates batching will only be allowed for same Provider or same Facility
(despite ED services being billed by TINs)
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.
“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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