Capitol Correspondence - 09.24.18

Medical Groups Concerned CMS Changes to Doctor Reimbursements Deter Seeing Complex Patients

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ANCOR is sharing the story below because of member expressed concerns about having difficulty finding medical providers willing to take on clients with I/DD..

According to Politico Pro:

“CMS thought a proposal to save doctors paperwork would be a public relations bonanza. Instead, most doctor groups view it as disastrous.

A provision tucked into the agency’s 1,472-page payment rule in July does away with a lot of paper-pushing, but it also appears to strip away the financial incentives to see patients with more complex conditions — upending a payment structure that has existed for two decades. The proposed rule followed months of consultation with medical groups, but many groups were caught unawares by the final product.


The uproar concerns CMS’ plans to make changes in the “evaluation and management” codes, last updated in 1997. Doctors like the proposed reduction in documentation, but not the perceived tradeoff: reduced payments for time spent with difficult patients, with incentives for quick visits. CMS has tried to mitigate the problem by adding bonus payments for treating sicker patients, but the solution doesn’t go far enough, doctors’ groups and academics say. [Emphasis added by ANCOR.]

At a news conference Monday, CMS Administrator Seema Verma called the proposed changes in the evaluation and management codes “the most comprehensive” since their inception. […]

The medical industry has issued many critiques of the current guidelines, including a 2015 position paper from the American College of Physicians. But the CMS rule didn’t accomplish what the doctors were seeking.

The original CMS evaluation and management rule, issued in 1995, was meant to inform doctors about how to write notes providing evidence of the amount and intensity of work they’d done during a clinical visit. The more intense the work, the more payment they received, with up to five levels of intensity possible.

But in the digital age, especially, the documentation has become repetitive, as doctors used formulaic notes to justify billing the most expensive codes possible. While imposing a high level of busy work, the guidelines facilitated exaggeration or outright fraud. A 2012 HHS inspector general report suggested some doctors were cheating the system.


CMS rejected the 2015 doctors’ proposals, leaving the problem unsolved as the Trump administration took power. Overhauling the requirements looked like a natural target for the deregulation-minded newcomers.


But collapsing the codes means doctors will be paid less for treating complex patients over long periods of time, critics say, because the most intense levels of care won’t be rewarded accordingly. According to an analysis in the New England Journal of Medicine, a doctor seeing a complex patient over half an hour or more could better spend her time, financially speaking, seeing three simpler patients. [Emphasis added by ANCOR.]

CMS thinks it can ease that problem by adding side codes that reward doctors for lengthy visits and treating complex patients. Yet even so, some specialty groups say their payments will be cut harshly. The American Society of Clinical Oncology, for example, thinks the new payment rule will cut payments for oncologists and hematologists by 4 percent overall. Opthalmologists and interventional cardiologists would also see big pay cuts.”