Posts tagged with rvu

I'm looking for some volunteers to test out our new 2007 RVU Calculation Tool. I have links to 2003-2006, but those don't work yet - I want some feedback about the 2007 first.

I put this tool on-line because, thanks to the AMA, it is very difficult to freely do any kind of CPT or RVU analysis. Their excessive view of their copyrights, in our opinion, actually limits progress and hurts their very members (the physicians) at the benefit of - get this! - United Healthcare. You know, the people who own Ingenix, the company that makes you pay a lot of $$ to get data that you are required to use by law and can find in the Federal Register?

Anyway, once I get enough feedback about the 2007 tool, I'll add the pieces for 2003-2006.

I've added 2003-2007!

Over the next few days, I'm going to post a sampling of stories of the things I've seen from our clients just this week regarding insurance negotiations. As so perfectly put by Dr. Rogu in a recent comment, awake sleeping giants! Identifying information has been removed.

So, from client #1:

...after review and some quick negotiation, it was obvious they were not willing to budge. We were done. A few companies had moved to [HMO] but not a major problem. Recently (the July 1 thing) the [local] union decided to go with [HMO]. Moms asked what they needed to do to get us to sign with [HMO]. I replied to two that we had reviewed the contract and there were major problems. Unfortunately, [HMO] was unwilling to make any changes. Naturally, I added, "They may listen to you. We would be willing to talk more if [HMO] is willing." I could almost hear you whispering in my ear, "That is just what you should say."

These moms, along with several of their friends who also bring their children to us, went to the enrollment meetings and talked to the union officers. I will avoid the specifics, but it wasn't pretty. Within one week, [HMO] reps were back talking to us and with a significantly higher reimbursement rate. Of course, we wanted to see the entire schedule and noted vaccines were paid at a low rate (their "purchase price" was below AWP). They did offer to allow us to enter their buyer's group. Secondly, we negotiated an increase in codes that had no "Medicare value" from the 60% you mentioned in your post to 80-85% depending on the plan. This improved the non listed administration fee from 60% of billed charges to 80-85% of billed charges.

After discussion, we have decided to "adjust" the administration fee for imms administered to [HMO] patients to reflect our administration costs INCLUDING the cost of ordering, storing, and cost of money. We are happy with this and think it is cool that Partner already has this capability.

Always one to keep pushing our clients, I asked: "How much is the difference worth?"

The answer?

It is my understanding that payment went up 20-25% in the 140% of Medicare for E&M codes. Total counting lab, x-ray, and imms put us at 125-130% of Medicare.

Anyone else here routinely getting 125-140% of Medicare?

There are many great things about this post, but there's one huge lesson to learn:

Don't tick off the moms.

For some time, we have known that our customers who use the "new" imms admin codes tend to get paid better for them. We figure, just as Dr. Bradley stated at the PCC-sponsored Coding event in NYC recently, that many of the MCOs simply entered the new codes with the new values but didn't update the original codes with the new values.
Wait - unless you know exactly what I'm talking about, that won't make sense. In 2005, CMS introduced the new vaccine admin codes - 90465/90466 (there are others, but these are the doozies). At the same time, they more-or-less doubled the RVU value of all the standard admin codes. We're talking about going from <$10 to >$20. It's a big deal and PCC has many customers getting the new, higher rates. Plus, it's proper coding.
So, even though we still meet and work with practices who don't yet use the new codes - no joke - we have plenty of information that indicates that using the new codes pays off.
Recently, the AAP asked us to look into this issue (and the "-25 modifier" issue, the results of which will follow). Here is some data you simply will not see anywhere else. Sure, some folks have it, but no one else will share. We will, because this is important. So, for 2006, here's what PCC clients did:

There you have it - the average reimbursement for PCC's customers across the country for a 90465 is 62% of Medicare vs. 50% for the 90471. Or, on average, $3 a pop. If you're not using the new codes - and setting your prices properly - then you are losing money. Lots of it.
Oh, yes - I am ignoring that "62% of Medicare" bit. It makes my stomach turn.

My apologies to the readers of the SOAPM mailing list, as this is a repeat, but there are too many folks who would otherwise miss this piece from the San Francisco Chronicle:

Doctor-insurer disputes force parents to pay up front for shots

It's the children who feel the sting of vaccinations, but it's their
parents who can get stuck with a sharp bill for shots they thought their
health insurance would cover.

Some pediatricians, faced with a growing number of recommended
immunizations and rising prices, are starting to restrict or refuse to
administer some vaccines unless patients pay in advance - and the prices
can add up to hundreds of dollars.

East Bay Pediatrics Medical Group, for example, which has nine full-time
physicians and offices in Berkeley and Orinda, informed its 1,800 Blue
Shield of California patients that, as of Aug. 1, physicians would not
administer four specific immunizations without payment up front....

"This is a business dispute, but the parents and kids are being squeezed
in the middle of this," said Dr. Myles Abbott, a pediatrician with the
group.

The piece goes on in some detail (and, whatever you do, don't read the comments from readers), but Dr. Oken was able to provide additional insight on the SOAPM list:

Two items that were incorrectly mentioned in the article : 1. They are not offering to pay 100 % AWP (in fact they want to reimburse Prevnar at below our acquisition cost). 2. They are not the "highest reimbursing health plan in California."

I agree with the practice that it is sad that it has to come to this. But, ultimately, we (the consumers of health insurance) need to play our parts. It's going to get worse before it gets better - we're going to see more of these fights, no question.

[Note: Since this post, there are have been major changes to the RVUs. Check more recent posts in this blog, like this one.  You may also want to go directly to PCC's on-line RVU tools.]

First, a sincere thank you to Linda Walsh at the AAP for this update. Linda is like a sharp dagger who cuts through all of the baloney for me when I get confused about some CPT or RVU issue. She must get a dozen questions (or more) a day from AAP folks and always answers them quickly, graciously, and - most importantly - correctly. And she even responds that way to me!

So...race to the URLs below to see the latest information from the AAP about 2008 RVUs, etc.:

• http://www.aap.org/visit/coding.htm
  (AAP public site)
• http://www.aap.org/moc/reimburse/codingrbrvsresources.htm
  (AAP Member Center)
• http://www.aap.org/visit/rbrvsbrochure.pdf
  (direct link to RBRVS Brochure)
• http://www.aap.org/visit/RBRVSConversionSpreadsheet.xls
  (direct link to RBRVS Conversion Spreadsheet)

Here's the most important section from the brochure:

2008 Medicare Conversion Factor = $34.0682 (Note that this is an 11% reduction!)
Additional components of the Medicare RBRVS physician fee schedule factored into the payment structure include the following:

MEI: The allocation of RVUs to pools for physician work, practice expense, and professional liability insurance, have been revised to correspond with the Medicare Economic Index. Work is now allocated 52% of the total RVUs, practice expense is 44%, and professional liability insurance is 4%.

HPSA: Incentive payments for physician services provided to patients in Health Professional Shortage Areas (HPSAs), which are medically underserved communities, urban and rural locations that have a documented shortage of medical professionals.

Non-Par Physician: Reduced payments for physicians, called “non-participating” physicians, who do not accept “assignment,” the Medicare approved amount that consists of the 80% Medicare payment and the 20% patient co-payment, as payment in full for services rendered to Medicare recipients.

Budget Neutrality: Statutory guidelines indicate that revisions to the RVUs for physician services may not alter physician expenditures within the Medicare RBRVS physician fee schedule by more than $20 million from the principal expenditures that would have resulted if the RVU adjustments were never initiated. CMS normally maintains Medicare budget neutrality exclusively via annual adjustments to the Medicare Conversion Factor. However, in 2008 the Medicare program will additionally apply a separate budget neutrality adjustment factor to the physician work RVUs to ensure Medicare budget neutrality in light of work RVU increases tied to the 2005 Five-Year Review.

I was in the middle of re-stating these facts when I realized that Linda Walsh said it as well as I could:

As you know, CMS once again implemented its work adjuster to allow for Medicare budget neutrality in light of the increases from the last Five-Year Review.

For 2008, the adjustment factor increased to 0.8806. CMS will adjust the work RVUs on each code submitted by this factor prior to payment of Medicare claims. Non-Medicare payers may or may not follow suit.

Two important points from this:

1. Because the PE portion of many codes continues to rise as a result of changes made two years ago (e.g., E&M codes received a significant boost), the total value of each code is offset by a growing reduction to the Work portion. This is required because of CMS's "budget neutrality" rules which require them to maintain a constant budget. In English...CMS raised the values of a lot of codes, but in order to keep the total they pay out constant, they also lowered everything at the same time. Following this? I'll run some numbers in a week or two predicting the impact on pediatricians, but it will be slight.
2. Much more important is this line: "Non-Medicare payers may or may not follow suit." There is absolutely no valid reason, of which I am aware, that a private payer should be making "budget neutrality" adjustments to their payments. It's patently absurd and unethical, imo. Those adjustments are purely for Medicare legal reasons and are not part of the RBRVS valuation system. I know of some MCOs are that making this adjustment and some who aren't. Fight this, bitterly.

In a few weeks, I will update PCC's RVU calculators to reflect the 2008 data but will not be including the adjustment factor above.

I hate parroting things from PedTalk and elsewhere, but this one is big (and it's a tough week). Straight from Susanne Madden, of course, is an update to a previous important announcement from UnitedHealthCare and the AAP that was made at the SF NCE:

United has decided to 'delay indefinitely' their implementation of the claim system enhancement that would allow for processing of multiple procedure modifiers (i.e. -25 and -59). This enhancement was first announced in the January 2007 bulletin, and was slated to be implemented in the second quarter of 2007. You will note that in the current bulletin, United is stating that its previous announcement listed an implementation date in the fourth quarter.

As soon as I get word about how this affects their previous promise to the AAP to begin these payments on December 8, I'll let you know. We'll even ignore the fact that it was supposed to begin at the beginning of the year.

You can see their bulletin announcing this change if you want to get angry. Note that there is no explanation for this delay whatsoever. In fact, check out the language:

Multiple Procedure Policy – Update
In the January 2007 Network Bulletin we communicated details about a system enhancement that would enable UnitedHealthcare to begin considering the codes with 0.00 Relative Value Units (RVU's) when applying multiple procedure reductions. This proposed enhancement was targeted for implementation in the fourth quarter of 2007. The claim system enhancement that would enable UnitedHealthcare to consider the reducible codes with a 0.00 RVU has been delayed indefinitely. Please refer to the January 2007 Network Bulletin for the full details on this enhancement.

I do this stuff for a living, and I would have blown right by that - notice that there is no mention of a "-25 modifier" or anything that would catch your eye? Thanks to Susanne for knowing how to read these things.

I have two you'll-see-it-here-first-if-not-only reports to provide you about the 2008 RVUs, but I'm reloading my personal machine (new hard drive) and I can't get to them until Friday. Until then, you have to suffer with this important FluMist news.

Why are these news items important? I've now seen major advertising or health articles for "needle free flu shots" five times this week. The local newspaper, on a poster(!), even on-line. These ads never, of course, mention that the shot may not be covered by your payer or may not be available. Just that you, caring mom, should go get them.

In fact, did anyone catch the AAP ad during ABC's "Grinch" movie tonight?!

Expect an influx of FluMist demands - and related problems - as a result. [Note to self: see if our clients are using more FluMist so far this year.]

As a result, two very important notes liberally borrowed from PCC customers posting on SOAPM:

Before this season we confirmed with essentially all our carriers that Flumist was going to be covered this year. However, UnitiedHealthcare and Horizon BC/BS [NJ] are denying coverage to the 2-5 segment as "not covered" or "not appropriate" for age, despite the FDA recommendation. UHC says they will pay after 1/1/8. Horizon may be a glitch. But be aware and ready to dispute denials.

And, this really from MedImmune (maybe I can get Dr. Walker to chime in) via Dr. Stoller. I'd post a link rather than quote it all, but I can't find it on their site:

...MedImmune has recently experienced a surge in demand for FluMist this season due primarily to an expanded age indication to include eligible children 2-5 years of age and a favorable recommendation by the CDC Advisory Committee on Immunization Practices (ACIP) for coverage within the indicated population for the VFC program. Due to these factors, MedImmune is temporarily depleted of inventory. MedImmune may not have additional product available until after Thanksgiving or into early December...

Now, here's the really funny part.  I was looking for the info above on-line and went to the FluMist site.  There, I entered my zip code to find the closest practices who could Get Me My FluMist.  Dr. Stoller's practice - in New Jersey - is the 8th closest to my home here in Vermont.  What are the odds of that?

We have had confirmation that the recent bulletin from UHC interpreted to mean that they intended to delay -25 modifier payments indefinitely does not refer to the -25 modifiers!  They are still on track for a Dec 8 "release" with backdating to October 15.  Reason #15 to always bill for things even if you don't get paid.  We have far too many clients who won't have any modifiers to back-bill.

More RVU madness in a few minutes.

Each year, when the new RVU values and rates are announced, a tremendous amount of attention is paid to the "Conversion Factor" - is it going down 10% this year, after all? Will the cut only be 5%? Could it go up by 5%?
Most of the time, little attention is paid to the subtle changes that are made to the GPCI, or the geographic adjustments that are made to each and every code. Well, I ran through all of the locations today and came up with a table outlining the effects of the GCPI in 2008. Some important ones in here.
Reading this table is straightforward - in addition to any changes that might happen on a code level or to the Conversion Factor this year, practices in Ventura, CA will receive a 1.6% increase of their rates from 2007. Santa Clara, CA, on the other hand, will have a 4.4% reduction.
That's huge!
Quick numbers: the average location loses a little more than 1%. Only 17% of the locations are getting an increase. The big losers are largely rural states with low costs of living