Anthem Lobbying Hard to Slash TKA, THA Pay

Are Anthem’s assertions true? How can anyone tell?

Here are three factual issues with Anthem’s sweeping claims about postoperative care:

1. There is no significant evidence to back up the claim that surgeons (or other providers in the practice) don’t perform follow-up visits covered by 10-day and 90-day CPT codes.In the past, CMS never required any reporting on postoperative visits. Then, Congress told CMS in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to find out more about postoperative visits. It was not until July 2017 that CMS began requiring reporting on postoperative visits for 10–day and 90-day CPT codes. That requirement was imposed on only nine states. As far as we can tell, nothing has been published so far from this data-gathering.

2. As most surgeons know, it is common that within a hospital, ambulatory surgery center, or other surgery-performing business entity, postoperative care is rendered by a hospitalist or other provider within the CPT code.
3. Also, CMS has an option under which the patient may receive post-op care from another business entity provider under the code.

CMS has a CPT billing code modifier under which the surgeon can choose to bill for the pre-surgical visit and the surgery only. Then, another organization, under an agreement with the surgery performer, bills under the same CPT code for the same patient with a different modifier for the postoperative care. Thus, the surgery could be performed at a hospital, and the post-op care could be done by a physician practice, each taking part of the payment. This is quite common.

Given the fact that no records were required, anyone asserting that post-op care was not rendered within the 90-day surgery CPT code would have to check for post-surgery visits by each surgery patient to other caregivers than the surgeon, including caregivers at other corporate entities, and then determine whether they were correctly billed.

Taken together, these sets of facts mean that no one has a substantial body of facts to back up Anthem’s accusation.

The other complaint is that surgeries don’t take as long as the time calculated into RVUs. The Urban Institute study cited by Anthem observed and measured the time taken in operating rooms to do the surgical procedures at only one hospital and used data from electronic health records in two others.

This study gathered a lot of data from those three. However, their surgeons might be faster on the average than most, or their cases might be less surgically complex. It’s a tiny sample—three hospitals out of 5,534 (American Hospital Association statistic). In addition, the surgical teams in the studied hospitals might have been speedier than normal because they knew they were being watched.

Why is CMS hiding the Anthem letter?

CMS seems to have ignored all prior complaints going back to at least 2013 about allegedly inflated RVUs until Anthem wrote its letter. Consider this additional evidence:

1. CMS didn’t cite the 2016 Urban Institute study (which CMS itself commissioned); it cited only Anthem’s February 2018 letter as its reason for reviewing the seven CPT codes.
2. CMS specifically brushed aside other patient-advocacy groups’ and individuals’ comments, choosing to act only on the Anthem letter.
3. CMS referred to that letter only as a letter from the “public,” even though it was written by a big national insurance company which stands to profit handsomely from reducing RVU payments. Why?
4. CMS seemed to have deliberately made the Anthem letter difficult to find. (AAHKS was apparently unable to find it when it referred to the letter as the “anonymous submitter.”) CMS didn’t post the URL of the Anthem submission in the final rule. In fact, if Anthem’s letter is still in the Federal Registerpublic submissions docket where it was posted in February, we couldn’t find it in two searches totaling about two hours. If it is not still there, why not?
5. CMS did post a link to the letter, on a CMS web page which is not only obscure but is written in language which is extremely vague as to what it’s about—and the letter triggering the review is the very last of 25 links at the bottom of the page. Not only is this letter the last of 25 links, but nothing in the page or in the URL at the bottom hints either that it’s the decision trigger or that it comes from Anthem.

Perhaps it is just a series of coincidences, but it appears from all this that CMS was trying to characterize Anthem, a 400-pound gorilla among MA insurers, as just some 400-pound guy on his bed. Here’s the page with the letter in the 25th link at the bottom; would you have found this page, or then found the Anthem letter once you reached it?