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The marathon process to create a new set evaluation and management (E/M) guidelines that pleases both providers and regulators hit another bump when the American Medical Association’s House of Delegates recently voted to pressure Medicare to postpone the latest proposed pilot test until August 2001 — at least. The AMA is also lobbying physicians to refuse to participate in any pilot study of E/M guidelines because of concerns about their potential legal exposure.
"The question is: Are the 2000 guidelines that problem-solving, simplistic, easy-to-use, and appropriate?’ " says Pensacola, FL, neurological surgeon Troy Tippett. "The answer is, We have no idea,’ although HCFA is asking us to acquiesce without having the prime component available to us — the vignettes."
Paul Rudolf, medical officer and senior technical advisor to HCFA’s Center for Health Plans and Providers, hopes HCFA can gain the medical community’s support for a set of E/M guidelines. "We certainly want to work with the specialty groups," says Rudolf. "We’ve heard [their] concerns."
Before this can happen, the question of immunity for providers that do choose to participate in any E/M pilot tests has to be settled. Then there is the question of the vignettes that make up the core of the new E/M approach. "Physicians have some very grave concerns about the process of obtaining the vignettes," stresses Tippett.
HCFA originally promised specialty societies would develop the examples, but instead, the agency outsourced them to a contractor, Aspen Systems. HCFA then told specialists they would be given the vignettes for comment after they had been created.
The proposed vignettes are intended to encompass three levels of physical complexity: brief, detailed, and complex. They also would illustrate three levels of medical decision making: low, moderate, and high. The Aspen contract was written to cover 20 medical specialties, each receiving five clinical examples. A first-look progress review of the project is scheduled for early 2001 — with another during the summer, when the work is supposed to be finished.
To avoid the possibility of an audit some physicians downcode their service below what they might be able to charge. And since the guidelines will be the basis for determining the level of service they can bill, physicians want to make sure the vignettes accurately reflect the practice standards of their specialty.
Another problem has been HCFA’s refusal to grant immunity as a condition of participation in a pilot study for the 2000 E/M guidelines.
Some providers also feel HCFA’s refusal to consider outliers — and physician review of those outliers as part of its fraud fighting efforts — adds insult to the potential injury by inferring doctors can’t be trusted. "We have peer reviews because we don’t want bad actors in our profession. We are trying to run a clean house. If [HCFA] would let us work with them, we could get rid of fraud," argues Elvyn L. Sterling, an Orange, CA, internist.
"HCFA should focus on finding fraud. Instead, they are trying to smear our profession," Sterling says.