Government alliances key to changing pay policies


As health care payment policy is changing at a rapid pace, many have found that partnership with the government is the best way to affect overall payment policy.

Payments for services in health care come by way of contracts, whether you are in private practice or an employee of a large specialty group, hospital, or other entity. Unfortunately, contracting is not easy, and contracts are influenced by many factors. In today’s market, many feel that the only choice they have in negotiating a contract is not signing an agreement. While not signing a contract is often the right choice for the practice, opting out of everything is rarely a smart decision.

As health care payment policy is changing at a rapid pace, many have found that partnership with the government is the best way to affect overall payment policy. Reducing headaches from far-reaching policies has become too much for any one group, and working on state or national legislation has become an important tool for the practice of medicine.

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The evolution of this process presents an interesting conundrum for many physicians. Government policies have created a morass of administrative guidelines that are a struggle to implement and result in receiving reduced payment from Medicare. The Affordable Care Act has influenced the marketplace dramatically, creating an environment that is just short of outright chaos. How can one possibly trust the government to assist in anything?

The history of governmental influence in the health care marketplace is long and convoluted. We will not attempt to provide an overview of this history; instead, we would like to recognize a few of those who, as volunteers, have been working on your behalf. There are too many to name them all, so we are going to mention those working on your behalf as groups. But bear in mind that the work of many is performed by a few and they all deserve our gratitude and support.

In our travels, we have heard many complaints about the representation that urology receives in the legislative process. We admit that no one is perfect, but more often than not, volunteer urologists and support staff from the AUA, urology offices, and friends of urology, like ourselves, fight to keep the practice of urology independent and viable as a business. Unfortunately, “we” do not always win and lately we have suffered a few setbacks. On the other hand, there have been some wins and there are opportunities for more.

The Medicare fee schedule and payment rules function as the backbone of the current payment system. In addition to being used by Medicare, Medicaid, TRICARE, and other federal entities, the Medicare payment system is used by nearly all private payers to update their systems in varying degrees and forms. The American Medical Association’s Relative Value Scale Update Committee (RUC) makes recommendations to the government for appropriate relative values.

Next: Urologists push RUC efforts

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Urologists push RUC efforts

Urologists have been part of this process from the beginning and have done an unbelievably good job of keeping our relative values high compared to our colleagues. Basically, the committee works by recommending the work values for new services based on physician survey data. They are also now charged with defending the relative values that were previously set but are now considered misvalued by the Centers for Medicare & Medicaid Services.

The values recommended by urology representatives must be defended within the AMA RUC. Final recommendations of the RUC are then sent to Medicare, which has the option of accepting the recommendations or modifying them. In addition to data from surveys, this process requires strategy and coordination.

Understand that we are in a period in which the system is trying to reallocate funds from surgical specialties to primary care. This push usually translates to decreases in value for codes that are resurveyed, most not by choice at this time. It also means that new codes and new values are opportunities to revalue similar codes to lower rates. You can help by responding to requests to participate in physician work surveys.

New CPT codes and the retirement of unused codes or rewording of descriptors of different codes are the purview of the CPT Editorial Panel. Again, the AUA has representatives and staff dedicated to the support of the CPT coding system. The process is long and carefully approached by the AUA and AMA. Striking a balance between correct and complete coding and the maintenance of values that will eventually have to be assigned to these codes by the RUC is difficult and highly regulated by the AMA process. The process for a new CPT code for new technologies is long and tedious, and it’s important to understand that the system is in some ways its own worst enemy. New codes have to represent widely used services or procedures in order to be considered, been granted FDA approval, and be supported by peer-reviewed literature. A balance between utilization and the painful process of obtaining reimbursement for services without a CPT code is considered prior to accepting a new code and the impact each entails.

The AUA Coding and Reimbursement Committee (CRC) is involved in both the CPT and RUC, as well as policy decisions that are brought by third-party insurers including Medicare. The work by the CRC impacts every urologist and requires significant time and effort from the staff and volunteers.

You may be asking yourself, “Why do I need to know about these efforts? I am just a hard-working practicing urologist.” The reason is simple. If you see inequities in the system and/or rules that prevent you from being paid appropriately for services, the best way to bring about change is to write a letter to the CRC. Detail the problem and your suggested solution. The CRC and the AUA or AMA cannot always solve these issues, but the best way to effect change is through the consolidated approach of the specialty voice.

Next: States finding solutions


States finding solutions

The states are becoming increasingly important as a melting pot for new ideas and new ways for delivering health care, paying physicians, solving systems problems, etc. One good example in which we are directly involved is Colorado’s Clean Claim Task Force, which is an effort to simplify the claims processing system by implementing a single claims edit for all private payers. What a novel idea! Again, urology is represented well in the process, focusing on correct coding from a clinically based approach. The AUA was one of the first specialty organizations to join this effort 2 years ago.

Other states are looking at adopting a similar approach, and we could use more. Like the concept of prompt pay and all-payer claims datasets, the more states that adopt legislation to follow the ideals of the single edit sets, the more likely the solution becomes a reality.

Other state groups have also pursued the goal of simplifying health care administration through state legislatures. One example is Ohio (through the Ohio Urologic Society and its State Government Affairs Monitoring Committee), which has been active in bringing revision to PSA testing guidelines and prior authorization. Ohio physicians are also bringing attention to tort reform needs, physician unions, problems with Medicaid expansion, and compounding pharmaceuticals. Specifically, they have developed an excellent working relationship with the Carrier Advisory Committee in Ohio and in dealing with the Medicare Administrative Contractors medical director.

Other model state urologic societies and collaborative efforts among urologists and state medical societies such as those in Florida, Washington, and California have made significant inroads with legislators to block efforts to remove ancillary ownership, revise men’s health initiatives, and decrease administrative roadblocks.

Additionally, the AUA and state groups have been supplemented in their efforts by the American Association of Clinical Urologists, the Large Urology Group Practice Association, and other subspecialty groups at the state and national level.

Although we have avoided mentioning the names of the individuals who drive many of these efforts, again it is often the work of a few motivated urologists and the staff of the organizations that do the majority of work. We see a strong need for more to be involved. Support can be provided in many ways. Financial contributions to political campaigns, political action committees, societies, and special interest groups are more critical than ever. Donating time is also key. Consider getting involved locally or nationally with your societies and the AUA Practice Management and Public Policy committees.

The chaos of today’s health care marketplace evolution requires a unified voice in supporting the practice of urology. It also requires that you build alliances with individuals, groups, ideas that you may not agree with 100%. Remember as well that the focus for these issues remains similar to those that you have in your daily practice. Correct coding, administrative cost reduction, and clinical relevance of services are all a part of the campaign for urology to maintain patient access to quality care.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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