CMS reimbursement rules for AAs

Terpole · Jun 6, 2013

Sooo....that settles it, for now, right?

jwk · Jun 21, 2013

Whoop de ******* do! Nothing has changed. AA's have always been medically directed. Just because some idiot pencil pusher at a regional CMS office decided to interpret some regulation differently doesn't change state law.

As far as Janice Izlar's comment - the ruling from CNS says ABSOLUTELY NOTHING about "The action taken by CMS represents an important development in anesthesia services coverage, clarifying what we already know: CRNA and AA educational preparation and services are not the same". That's simply political pandering to her minions.

allnurses Guide · Jun 22, 2013

Uh huh....AAs are supposed to be only be billed under medical direction, but obviously that was not the case everywhere. Billing under medical supervision allowed for AAs to bill for more than 50%. This action limits AAs to what they are medically directed assistants where the TEFRA rules are supposed to be followed in all cases, but the vast majority of anesthesia cases do not meet TEFRA requirements. Now if I was politically savvy or financially motivated CRNA that worked at a large ACT practice I would start documenting all the times the TEFRA rules were not followed and turn anesthesia company in for billing fraud for all those AAs that are not medically directed.

jwk · Jun 23, 2013

Uh huh....AAs are supposed to be only be billed under medical direction, but obviously that was not the case everywhere. Billing under medical supervision allowed for AAs to bill for more than 50%. This action limits AAs to what they are medically directed assistants where the TEFRA rules are supposed to be followed in all cases, but the vast majority of anesthesia cases do not meet TEFRA requirements. Now if I was politically savvy or financially motivated CRNA that worked at a large ACT practice I would start documenting all the times the TEFRA rules were not followed and turn anesthesia company in for billing fraud for all those AAs that are not medically directed.

TEFRA rules, as you know, refer to billing practices for anesthesia. They apply to AA's as well as CRNA's. A practice that chooses to bill under "medical direction" indicates that an anesthesiologist is providing medical direction to no more than four AA's or CRNA's at one time. Even in a practice that doesn't have AA's at all - billing under medical direction means that no more than four CRNA's were directed at any given time. TEFRA was not created in response to groups using AA's. You know this of course - you just skew everything to further your own political leanings.

Your continued claims that "the vast majority of anesthesia cases do not meet TEFRA requirements" borders on libel because it simply isn't true. You have absolutely zero evidence or proof of this - it's not based in fact. You think it happens - you hear that it happens - you hope it happens. It doesn't. It's wishful thinking on your part and the part of organized nurse anesthesia to further their fondest fantasy of independent CRNA-only practice throughout the country. By all means - please provide any proof that you might have - surely there is a big juicy story out there somewhere of CMS clamping down on a group for fraudulent billing regarding medical direction. The threat of triple-damages and loss of CMS as a payor is a pretty potent motivator for groups and hospitals and practices to keep things legal.

It's interesting to me that CRNA organizations would actively encourage their membership to act as whistleblowers against their employers simply to further their own political agenda. And then you wonder why some groups are preferentially hiring AA's over CRNA's? (several groups in Missouri and Colorado in 2012-2013 come to mind) You wonder why a number of practices have stopped participating in CRNA training and acting as clinical sites. Why should anesthesiologists continue to work with and support CRNA's whose stated intent is to drive them out of business, when there is another choice of anesthesia professionals who choose to work with them instead of against them?

nomadcrna, DNP, CRNA, NP · Jun 28, 2013

1. Why is jwk in a CRNA forum? Are you that insecure?

2. So organizations should NOT want their members to follow the law? (reporting)

3. There was a recent study that actually showed that many ACT practices were not meeting TEFRA requirements. I'll find it.

4. Thankfully, as a CRNA I have a choice. I choose to practice independently and have for 22 years.

5. Nobody said TEFRA was created in response to AA.

6. Juicy lawsuit you requested. http://www.aana.com/newsandjournal/Documents/legalbrfs0402_p93-95.pdf

jwk · Jun 28, 2013

1. Why is jwk in a CRNA forum? Are you that insecure?

Been here for years - didn't know being a CRNA was a requirement - and apparently it's not since there are lots of non-CRNA's on this part of the forum. Are you scared of the debate?

2. So organizations should NOT want their members to follow the law? (reporting)

The motivation isn't some grandiose civic gesture - you of course know this.

3. There was a recent study that actually showed that many ACT practices were not meeting TEFRA requirements. I'll find it.

Please do - preferably one not sponsored by the AANA and it's associated lackeys.

4. Thankfully, as a CRNA I have a choice. I choose to practice independently and have for 22 years.

Congrats - and what is your opinion of CRNA's who choose to practice in an ACT practice?

5. Nobody said TEFRA was created in response to AA.

wtbcrna tries to give the impression that TEFRA rules apply only to AA's.

"Uh huh....AAs are supposed to be only be billed under medical direction, but obviously that was not the case everywhere. Billing under medical supervision allowed for AAs to bill for more than 50%."

6. Juicy lawsuit you requested. http://www.aana.com/newsandjournal/Documents/legalbrfs0402_p93-95.pdf

I see - an action more than a decade old - surely this demonstrates that rampant violations continue, correct?

nomadcrna, DNP, CRNA, NP · Jun 28, 2013

2. So no answer. Nothing said that is it illegal for the CRNA to NOT report it.

Now this is a post of yours on another site. Telling a different story? Does not help your credibility any does it.

09-14-2010, 03:25 PM

Hey goto

jwk stated on 09/14/2010

I dont think you are correct here. It IS the responsibility of everyone who is billing (which includes the CRNA even if the billing is done by someone else) to meet all COP of CMS. Ignorance is not a defense and neither is allowing the MDA to commit fraud. It is, indeed, the responsibility of the CRNA to document an MDA is not meeting the 7 TEFRA rules otherwise they to will be committing fraud as an accessory. Allowing fraud to happen MAKES you culpable and ignorance is not a defense in the eyes of the law.

3. Do you even understand the scientific peer review process? If you did, you would not make a statement such as this.

4. Personally, I think all CRNAs should refuse to work in an ACT environment. Nothing in that paragraph suggests that the rules only apply to AAs. The discussion is ABOUT AAs.

5. You did not specify a timeframe. You asked for any lawsuit. I gave you one. LOL

jwk · Jun 28, 2013

2. So no answer. Nothing said that is it illegal for the CRNA to NOT report it.
Now this is a post of yours on another site. Telling a different story? Does not help your credibility any does it.
09-14-2010, 03:25 PM
Hey goto
jwk stated on 09/14/2010
I dont think you are correct here. It IS the responsibility of everyone who is billing (which includes the CRNA even if the billing is done by someone else) to meet all COP of CMS. Ignorance is not a defense and neither is allowing the MDA to commit fraud. It is, indeed, the responsibility of the CRNA to document an MDA is not meeting the 7 TEFRA rules otherwise they to will be committing fraud as an accessory. Allowing fraud to happen MAKES you culpable and ignorance is not a defense in the eyes of the law.
3. Do you even understand the scientific peer review process? If you did, you would not make a statement such as this.
4. Personally, I think all CRNAs should refuse to work in an ACT environment. Nothing in that paragraph suggests that the rules only apply to AAs. The discussion is ABOUT AAs.
5. You did not specify a timeframe. You asked for any lawsuit. I gave you one. LOL

Not sure what site this is off of or if I even wrote it. (feel free to PM me the source so I can look up the whole post in context) Regardless - if you indeed sign a record in an ACT practice knowing that these requirements are not being fulfilled, that makes you culpable, and you shouldn't do it. I assume that much we agree on. However - an organized state and/or national campaign to actively promote "turning in" employers goes beyond that. I keep hearing that "it's a well known fact" that "most" ACT practices commit fraud, yet I have yet to see the study or ANY evidence. You and I both know the motive is to drive out ACT practices and promote independent CRNA practice in it's stead. You're not interested in billing fraud or saving tax dollars - you're simply replacing one form of greed with another.

If CRNA's want to refuse to work in an ACT environment, that certainly is fine by me. I don't see that happening to the majority of working CRNA's who actually work in an ACT practice, but if they want to empty out those positions to make a political statement and join the ranks of the unemployed, by all means, go for it.

nomadcrna, DNP, CRNA, NP · Jun 28, 2013

One form of greed for another? Really?

So wanting to keep the revenue YOU generate instead of being paid a fraction of your worth is only greed? Difficult to have an adult discussion with statements such as these.

"Active campaign to actively promote turning in employers" goes beyond that? Again, really?

Our association wanting CRNAs to actively follow the law is somehow bad? So how does this help your credibility when you state that "it is the responsibility of EVERYONE...." but when the associated says the EXACT same thing, it is somehow wrong.

You can whine about "no evidence" but obviously getting a "study" about illegal activity is difficult. You hear many CRNAs in ACT practices stating that they do not follow the TEFRA rules but that is not good enough.

Btw, this very topic was discussed, BY YOU on this site. allnurses.com CRNA forum*

You wrote it and I'm sure you remember it. Not many AAs with your name.

Keep talking, it is starting to get amusing. :)

Not sure what site this is off of or if I even wrote it. (feel free to PM me the source so I can look up the whole post in context) Regardless - if you indeed sign a record in an ACT practice knowing that these requirements are not being fulfilled, that makes you culpable, and you shouldn't do it. I assume that much we agree on. However - an organized state and/or national campaign to actively promote "turning in" employers goes beyond that. I keep hearing that "it's a well known fact" that "most" ACT practices commit fraud, yet I have yet to see the study or ANY evidence. You and I both know the motive is to drive out ACT practices and promote independent CRNA practice in it's stead. You're not interested in billing fraud or saving tax dollars - you're simply replacing one form of greed with another.
If CRNA's want to refuse to work in an ACT environment, that certainly is fine by me. I don't see that happening to the majority of working CRNA's who actually work in an ACT practice, but if they want to empty out those positions to make a political statement and join the ranks of the unemployed, by all means, go for it.

nomadcrna, DNP, CRNA, NP · Jun 29, 2013

Finally found one. Peer reviewed scientific study with appropriate methodology.

http://www.aana.com/newsandjournal/documents/comparison_napractice_1000_p452-462.pdf

Page 455 under results.

Only 1 ACT practice were the elements of medical direction for every case done.

Only 29% of ACT practices indicated that a MDA did the preoperative assessment.

allnurses Guide · Jun 29, 2013

Influence of supervision ratios by anesthesio... [Anesthesiology. 2012] - PubMed - NCBI

"Journal Anesthesiology Confirms that Anesthesiologist Supervision Often Lapses

Lapses in anesthesiologist supervision of CRNAs are common even when an anesthesiologist is medically directing as few as two CRNAs, according to an important new study in the March issue of the journal Anesthesiology. The study, titled "Influence of Supervision Ratios by Anesthesiologists on First-case Starts and Critical Portions of Anesthetics," looks at over 15,000 anesthesia records in one leading U.S. hospital and raises critical issues about propriety and compliance in the most common and costly model of anesthesia delivery at a time when quality and cost-effectiveness are white-hot healthcare issues at every level."