O.R. cases for CRNA's vs. Anesthesiologists

Specialties CRNA

Published

Hey guys. I was hoping I could get some CRNA's opinions on this matter.

Do you find that the CRNA's tend to do the "easier cases"....i.e. ENT and ortho, and then the MDA will do the more difficult cases, i.e. cardiac or complicated GI??

Is this true, or not true?? Can someone explain all of this to me ?

Thanks so much :)

Specializes in ICU; Anesthesia.

Our fellows do the 'hard' cases, hearts and peds. We usually do the rest but we are supervised.

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The anesthesiology groups that are simply operating off of greed by their partners and anesthesiologists will permit anyone, CRNA or AA, to do any case.

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Specializes in Anesthesia, Pain, Emergency Medicine.

If the partners are billing for cases, how would they make more money by letting a CRNA or AA do the case? Is it because they don't want to do it or want to "supervise" rooms while CRNAs make money for them?

I have a news flash, this is done in many, places. It is called the "team approach".

Thank god I'm independent and solo.

The anesthesiology groups that are simply operating off of greed by their partners and anesthesiologists will permit anyone, CRNA or AA, to do any case.
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It has been a "team approach" that is really a half baked approach to the delivery of anesthesia. I also think independent should rule....MDs should make themselves independent of the team approach, but in reality, most won't due to $$$$$.

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Specializes in CRNA, Law, Peer Assistance, EMS.
The anesthesiology groups that are simply operating off of greed by their partners and anesthesiologists will permit anyone, CRNA or AA, to do any case.

I see you operate from the erroneous assumption that a CRNA requires the permission of an anesthesiologist to give an anesthetic to ANY patient.

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If the nurse is being employed by the anesthesiologist, then yes, the nurse has to get permission and typically in a team approach will discuss the case in advance. In a situation where the states are non-opt out and the anesthesiologists are in a team approach with the nurses, then yes, typically they require permission. In opt out states, a nurse can give a general anesthetic without the surgeon or anyone else having any idea what is being done...it is indeed a complete independent practice. So, it all depends, doesn't it?

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Specializes in Anesthesia.
If the nurse is being employed by the anesthesiologist, then yes, the nurse has to get permission and typically in a team approach will discuss the case in advance. In a situation where the states are non-opt out and the anesthesiologists are in a team approach with the nurses, then yes, typically they require permission. In opt out states, a nurse can give a general anesthetic without the surgeon or anyone else having any idea what is being done...it is indeed a complete independent practice. So, it all depends, doesn't it?

Opt out has to with billing not independence, and since it is always the CRNAs license on the line it is ultimately up to the CRNA doing the case what the final decision is. "The anesthesiologist/surgeon said so" excuse doesn't hold up very well in a court of law or in front of your state BON.

There are independent CRNAs in every state. An opt out state just means that CRNAs can bill medicare independently without "supervision". In smaller hospitals this "supervision" requirement rule is met by having the surgeon(s) signing a form letter that is placed in the patient's chart, and contrary to what the ASA/AMA would have physicians believe this does not increase surgeon liability.

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If CRNAs are completely independent, then neither the surgeon in smaller hospitals nor the anesthesiologist in a team model would be found culpable at the end of litigation. Fact is, virtually 100% of the time the surgeon or anesthesiologist is named in a suit, and in a team approach, the anesthesiologist is always found liable if the CRNA is. You will have achieved complete independence in decision-making once CRNAs get sued independently of others and once the supervising anesthesiologists are dropped from the suits by the plaintiff without dropping the CRNA. But of course the rates for CRNA malpractice will rise substantially....many times what you pay now. I know some, such as wtbcrna are ready to go this direction, but I am not certain the entire profession is ready for this....

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Specializes in Anesthesia, Pain, Emergency Medicine.

Actually no, I would study up on the subject if I were you.

ONLY if the MDA is billing for MEDICAL DIRECTION does he need to meet the TEFRA conditions for payment. Opt out is ONLY for medicare conditions of participation. You can still be independent according to state law. You see, billing and practice are two different animals.

You can be employed by an MDA, do cases and bill NON-MEDICALLY DIRECTED.

If you are medically directed by an MDA, they must meet the TEFRA conditions.

http://lawmedconsultant.com/1305/anesthesiologist-misinformation-rampant-in-medicare-crna-opt-out

If the state is a non-opt out state, the CRNA can still function entirely without the MDA, even if employed by one. If the CRNA does an anesthetic for a medicare patient, he can bill either medically directed or non-medically directed. If non-medically directed, the surgeon is considered "supervising". But this is a general over-site, according to medicare.

the Medicare supervision requirement allows for a psychiatrist, podiatrist, dentist, surgeon, etc., occupied with their own particular procedure and lacking any training in anesthesia, to ‘supervise’ a CRNA by coincidentally being present in the operating room. The supervision requirement limits CRNA reimbursement to 50% of the anesthesia fee from Medicare leaving the hospital, and ultimately the patient, to make up this ‘supervision deduction’ so that the CRNA is paid a competitive wage. On the other hand, when a physician anesthesiologist is medically directing from 1-4 procedures simultaneously fulfilling the supervision requirement, that physician is reimbursed 50% of the Medicare payment for each patient. So while 4 CRNAs toil away providing the anesthetic, the physician anesthesiologist is collecting 50% of the money for each of those four patients. Medicare at no time requires an anesthesiologist to be involved in an anesthetic, it simply withholds their 50% should another physician provide supervision. Hospitals which employ only CRNAs as their anesthesia providers, typically rural hospitals, are tired of this practice bleeding them dry. CRNAs are equally disgusted that their anesthesia services, regardless of the presence of an anesthesiologist, are worth only 50% of the total reimbursement from Medicare. This is not the case with private insurance companies who reimburse 100% for non-supervised nurse anesthetists.

Billing:

It is also important to realize there is a distinct reimbursement difference between “supervision” and “medical direction.” While the terms are often used interchangeably by physicians, nurses, and office staff, they have two entirely different meanings. Medical Direction ([when] the physician has met all the requirements, if applicable) effectively pays 100% of the claim. Supervision, a claim that is filed with an “AD” modifier, indicates that the anesthesiologist was either involved with more than four concurrent rooms or cases (regardless of type of insurance) or failed to meet the medical direction steps in some states. Medicare penalizes supervised claims by paying a maximum of four (4) units per case, providing the anesthesiologist was present for induction. No time is allowed for any of the concurrent cases. You may be surprised to learn that some carriers pay absolutely nothing when an AD modifier is reported.

OK…now you should be confused

STATE LAWS REGULATING NURSE ANESTHESIA PRACTICE

Supervision or medical direction, collaboration, consultation, etc. are also terms used in various state nurse and medical practice act regulations….and there is no rhyme or reason as to when they are used or what they mean.

Independent CRNA practice has existed for over 100 years. Only 12 states require by law that a physician ‘supervise’ a CRNA’s practice of anesthesia as a matter of law.

40 states do not have any physician “supervision” requirement for CRNAs in their nursing practice or medical practice laws or regulations. If one includes clinical “direction” requirements in addition to “supervision,” 32 states do not have a physician supervision or clinical direction requirement for CRNAs. Including state hospital licensing laws or regulations, 33 states do not require physician supervision. Including state hospital licensing laws or regulations, 24 states do not require physician supervision or direction. No state requires a CRNA be supervised or clinically directed by an anesthesiologist.

In states which do require physician supervision, the supervising physician is not required to have any training in the practice of anesthesia or additional qualifications with the exception of New Jersey and Washington D.C. (exception applies in D.C. only when a general anesthesia is given). What constitutes ‘supervision’ or ‘direction’ is generally poorly defined or not defined at all. Usually the term hangs in the air without any reference as to what it should mean.

INSURANCE IS ONE THING……LICENSE REGULATIONS ARE ANOTHER

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Specializes in Anesthesia, Pain, Emergency Medicine.

Actually, the surgeon is always included in the suit if an MDA does the case. You are welcome to follow this link and get the correct information instead of your "opinion".

Much of what you opine below is not true.

" , and in a team approach, the anesthesiologist is always found liable if the CRNA is."

I just have to laugh at that.

You are confused about the concepts of supervision and direction.

If CRNAs are completely independent, then neither the surgeon in smaller hospitals nor the anesthesiologist in a team model would be found culpable at the end of litigation. Fact is, virtually 100% of the time the surgeon or anesthesiologist is named in a suit, and in a team approach, the anesthesiologist is always found liable if the CRNA is. You will have achieved complete independence in decision-making once CRNAs get sued independently of others and once the supervising anesthesiologists are dropped from the suits by the plaintiff without dropping the CRNA. But of course the rates for CRNA malpractice will rise substantially....many times what you pay now. I know some, such as wtbcrna are ready to go this direction, but I am not certain the entire profession is ready for this....
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The issue is liability. It has been a very nice dance around the issue in the past with CRNAs wanting independence but not wanting to tear down the shield that helps protect them. Perhaps that time has come. There are NO cases which I can find in which a MD in a team approach has not been named in a suit. Perhaps there are unscrupulous MDs that employ CRNAs but fail to provide assistance/supervision/direction/etc, and really don't give a flip about patient safety. I certainly agree that is often the case. However, this then gets into IRS regulations....it is not possible for a CRNA to bill independently of an employer. It will actually be interesting to see what transpires in the future, and I stand with CRNAs waiting for the unscrupulous anesthesiologists who employ gaggles? bevies? crowds? harems? (forgive me as I do not know what term is currently in use) of CRNAs to go down in flames.....

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Specializes in Anesthesia.
If CRNAs are completely independent, then neither the surgeon in smaller hospitals nor the anesthesiologist in a team model would be found culpable at the end of litigation. Fact is, virtually 100% of the time the surgeon or anesthesiologist is named in a suit, and in a team approach, the anesthesiologist is always found liable if the CRNA is. You will have achieved complete independence in decision-making once CRNAs get sued independently of others and once the supervising anesthesiologists are dropped from the suits by the plaintiff without dropping the CRNA. But of course the rates for CRNA malpractice will rise substantially....many times what you pay now. I know some, such as wtbcrna are ready to go this direction, but I am not certain the entire profession is ready for this....

Everyone in the OR is usually initially named in the suit. There are many cases where the MDA is not found liable and the CRNA is. CRNAs having lower premium rates has nothing to do with supervision, if you have an article with references to prove otherwise please post it. There are many cases listed below where the CRNA was held solely responsible.

http://www.aana.com/uploadedFiles/Resources/Legal_Briefs/2007/legalbriefsp89-93.pdf Article and cases about surgeon liability.

http://www.aana.com/Resources.aspx?id=2362 Surgeons sued/losing for the actions of working with directly with an MDA no CRNA.

The truth is CRNAs are just as safe as MDAs, and if the ASA could prove otherwise they would have a long time ago.

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