Don't assume anesthesia is covered
Don’t assume anesthesia is covered
Some carriers imposing stricter standards
It’s hard to imagine anesthesia services for breast cancer surgery as not being medically necessary, but Medicare HMO carriers in New York have recently refused to pay such claims based on that argument.
The New York policy is identical to a model protocol developed last year at a policy meeting of the nation’s Medicare carriers in consultation with specialists. Under the policy, carriers, for instance, would no longer routinely pay for monitored anesthesia care for a range of procedures. These include most breast surgeries, angioplasties, the insertion of permanent catheters into cancer patients for long-term chemotherapy, and most procedures on male genitalia.
Medicare carriers say their goal is simply to tighten procedures to eliminate abuse, fraud, and unnecessary care for instance, using the services of an anesthesiologist during removal of a mole, when the local painkiller administered by the surgeon is sufficient.
Physicians contend that as written, these new rules also exclude more complicated procedures, including all breast cancer surgeries short of a radical mastectomy.
Docs say biopsies may be discouraged
Moreover, the New York State Medical Society argues that these rules set a dangerous precedent that could undermine medical treatment for Medicare patients by potentially discouraging frightened, financially pressed older patients from getting a lung or a breast biopsied, while prompting inadequately trained surgeons to do the work of an anesthesiologist.
Many physicians say this confusion reflects the fallout that comes from payers’ increasingly common attempts to mandate one-size-fits-all policies to limit hospital stays, such as the so-called "drive-through" mastectomies and child birth deliveries that have recently been outlawed in some states.
"Fraud and abuse needs to be punished, but this policy unfairly targets anesthesiologists and patients, especially women, the elderly, and the disabled, " stresses Scott Groudine, MD, of the New York Society of Anesthesiologists.
However, when providers can document a significant underlying medical condition that makes the services of an anesthesiologist "medically necessary," the carrier will generally pay.
In general, this policy does not affect a surgeon’s routine use of local anesthesia, or an anesthesiologist’s administration of general anesthesia, in which a patient is put deeply to sleep, says Deborah Bohren, assistant vice president for media relations for Empire Medicare Services, one of three Medicare carriers in New York State. Rather, it is intended to apply only to "monitored anesthesia care," where an anesthesiologist often administers intravenous sedation in conjunction with the use of local painkillers by a surgeon, monitors a patient’s vital signs, and stands ready to take additional action, she says.
"The goal of the policy is to make sure any services provided are medically necessary," argues Bohren. "But based on these concerns . . . we are going to temporarily suspend the policy so we can get a dialogue in place with the appropriate specialists. If there are certain breast-cancer surgeries, for instance, that don’t fit, the policy may need to be tweaked and revised." Until then, Empire Medical is asking providers to resubmit any related claims that have been denied with an attached documentation of medical need.
The way the guidelines were written using anesthesia codes that correspond to regions of the body rather than to specific surgical procedures was a major contributing factor to the controversy, contend many experts.
"If someone has a one-centimeter mole on their skin, I’d agree they don’t need an anesthesiologist, " notes Groudine. "But if you have the same anesthesia code for taking out a quarter of the breast, then you can’t say we won’t pay for that, because they’re two different procedures and there’s a vastly different experience of pain."
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