PDA

View Full Version : Practice laws and political issues



TSICU83
10-23-2009, 01:56 AM
So I'm getting ready for some interviews and trying to become as knowledgeable as possible about all of the laws and regulations that govern CRNA practice. I have been researching this topic since before I decided to apply to school but it's hard to wade through all of the B**sh** that is out there on these issues.
My current understanding goes something like this: The federal law says that a CRNA must be supervised by a physician (not an anesthesiologist, but usually the surgeon who signs the chart afterward). This I understand is not true supervision but more "medically ordering the anesthesia". Then we have the opt-out states, is this strictly for medicare billing purposes or did it actually change practice? If the federal law is true how can independent practice be possible in no opt-out states? I have read many of the legal documents about how the surgeon and the MDA are not responsible for the CRNA, contrary to what the ASA and others say.
Many times I have read posts on this forum alluding to the fact that CRNA's are legally independent practitioners. I also realize that hospital politics may sometimes dictate the interaction between CRNA's and MDA's within their doors, limiting practice and imposing supervision. My long term goals include practicing independently and thus I want to be trained as a full service anesthesia provider. I don't believe that being trained in a limited manner does anything for the future of this profession. Thus, I must have my ducks in a row come interview time to not only answer questions they may have of me, but to more eloquently explain what I want in a program. Excuse the somewhat long and rambling post. Also, please correct the ignorance I have for the finer points of this whole political issue of supervision as the purpose of this post is to have all of you veterans out there educate me.

MmacFN
10-23-2009, 05:20 AM
The federal law says that a CRNA must be supervised by a physician (not an anesthesiologist, but usually the surgeon who signs the chart afterward). This I understand is not true supervision but more "medically ordering the anesthesia".


This is called medical supervision and is for billing CMS ONLY. There are 2 types of CMS billing. One is "supervision" which is most often used in the no MDA situation and there is no liability for the surgeon nor does it imply control by the surgeon.

The second is Medical Direction which only applies to MDAs so that THEY can get paid by CMS 50% of the billing for up to 4 cases they 'medically direct'. This is also a billing term and only applies to CMS.


Then we have the opt-out states

Opt out means noone is needed to sign anything for a CRNA to bill 100% of the CMS physicians fee schedule, that is it.



If the federal law is true how can independent practice be possible in no opt-out states?

Because independent practice implies the actual practice not the billing arrangements. You can work in a non opt out state and bill either CMS or private insurance (for full fees) and all the surgeon does is sign the chart. You can also work a cash buisness (plastic surgery) where no insurance is taken and bill 100% (no requirement to follow CMS billing rules). Remember, the CMS rules are ONLY about billing not practice and ONLY apply to CMS.


I have read many of the legal documents about how the surgeon and the MDA are not responsible for the CRNA, contrary to what the ASA and others say.

Correct. However, when an MDA and CRNA work together the involvement of the MDA will be investigated to determine culpability. So it is likely they will be named in the suit but if they did not cause the event (CRNA does something stupid and does not talk to MDA about it) they can be dropped (and vice versa).



Hope that helps

TSICU83
10-23-2009, 06:27 AM
Thanks Mike I think that clears it up for me. So I think the take home message for me in the future would be to pick and choose where I work after school(assuming I get accepted). It seems as though the hospitals and certain MDA run anesthesia groups are putting the restrictions on CRNA practice. I have shadowed many, many times and seen varying practice arrangements and heard about others second hand. I don't think I would be happy working in a place where the MDA "supervises" you and restricts your practice to not much more than taking vital signs and monitoring the patient. I once saw an MDA who pushed all the drugs and intubated the patient then left the room and came back to reverse paralytics, emerge the patient, and extubate. I have also seen the other end of the spectrum with total independent practice. I just don't know how one could be happy working under the former.

yoga
10-23-2009, 11:40 AM
I would like to take Mike's excellent answer a littler further.

1. Professional licensure and practice is determined at the state (not federal) level. In other words, the state nurse practice act defines the practice parameters of nurse anesthetists. THIS HAS NOTHING TO DO WITH REIMBURSEMENT.

2. The Federal government is in charge of Medicare reimbursement for professionals and facilities. Medicare Part B directly reimburses nurse anesthetists for professional services. This has NOTHING to do with Opt-out or any supervision requirments.

3. Old regulations required some kind of supervision for reimbursement for the services of nurse anesthetists. This was payment that went to the hospital or facility who employs or contracts for nurse anesthetists and bills for their service. This is under Part A. Because this practice was inconsistent with the part B direct reimbursement to CRNAs, the AANA attempted to get this reversed. While signed by President Clinton, it was reversed by President Bush and reverted to a system where each state makes a decision on the issue. In other words the state can opt-out of the supervision requirement for part A Medicare.

4. Opt-out and TEFRA are related to MEDICARE REIMBURSEMENT and are no way practice issues. I have been in private practice in an (until recently) non-opt out state for over 25 years.

5. Making a reimbursement into a right to practice issue is simply false and should never be done. It is critical that you learn the difference.

Go to the AANA (www.aana.com) for the most up to date information. They have the best data on the topic, while others are trying to make it into a practice restriction/political/power issue.

Jan Mannino, CRNA, JD

TSICU83
10-23-2009, 01:29 PM
Jan- thank you so much for your informative post. I have read about your private practice out west in some of the other discussions on this board and also noticed you had a book for sale on the AANA website. That must be so fulfilling to operate your own outpatient surgery center. I have visited the AANA website many times but find it somewhat difficult to negotiate all of the legal language involved in many of the documents. I am not a legal guru like yourself, but I do agree it will be critical for me to become familiar with all of the ins and outs of these issues as I progress in my career.

I do understand that these reimbursement policies and actual practice rights are two totally different things. However, essentially it sounds like they are somewhat related if you must have a physician sign off on your chart before you can get paid in a non opt-out state. Am I wrong in this assertion? Please correct me if so.
Also, would you mind commenting on my earlier statements regarding supervision and practice restrictions imposed by hospitals and anesthesia groups. It is curious to me that these tactics can be employed when there is no legal basis for them. What kind of experience have you had with these matters during your career?
Thanks in advance for your insight into these issues, your experience and expert knowledge is much appreciated.

yoga
10-23-2009, 03:05 PM
my career.

I do understand that these reimbursement policies and actual practice rights are two totally different things. However, essentially it sounds like they are somewhat related if you must have a physician sign off on your chart before you can get paid in a non opt-out state. Am I wrong in this assertion? Please correct me if so. .

You are partially wrong and a little off track.
1- Opt-out is ONLY a Medicare issue, so it doesn't have anything to do with other insurance payments. Blue Cross, etc have nothing to do with this.

2- A CRNA still receives DIRECT reimbursement from Medicare in all states, including non-opt out states.

3.This issue relates ONLY to Part A reimbursement to the facility for CRNA services. The facility may require some sort of acknowledgment of fulfillment of these requirements for reimbursement for the CRNA. Depending on your contract or work arrangement, it should NOT have an impact on how you are personally paid, but could have an impact on what the facility receives when they are reimbursed for your MEDICARE services.

All of the caps are mine and are for emphasis.

This topic really needs to be addressed at anesthesia schools. There is so much misinformation and misinterpretation out there and it is amazing how many people have opinions not based on facts.

PLEASE REMEMBER:
1. reimbursement and practice are two different things.

2. Medicare and private insurance reimbursement are two different things.

3. The individual states regulate our practice

4. There are multiple ways to get paid as a CRNA, very few of which have to do with opt-out directly.

5. Opt-out is a reimbursement issue, not a practice issue.

In my opinion, except for students, CRNAs DO NOT NEED TO BE SURPERVISED. I know some state laws have some contradictory language on this.

I know I come across strong on this issue. But in case you haven't figured it out...just about everything is related to money, power or sex.

If anyone has contradictory information and if I am not current in my facts, I welcome your input.

Jan

MmacFN
10-23-2009, 03:35 PM
nice answer

Also, TS, when you get your AANA number there are many more resources here on this website (in the hidden sections) which can edumacate you on these issues ;)


I would like to take Mike's excellent answer a littler further.

1. Professional licensure and practice is determined at the state (not federal) level. In other words, the state nurse practice act defines the practice parameters of nurse anesthetists. THIS HAS NOTHING TO DO WITH REIMBURSEMENT.

2. The Federal government is in charge of Medicare reimbursement for professionals and facilities. Medicare Part B directly reimburses nurse anesthetists for professional services. This has NOTHING to do with Opt-out or any supervision requirments.

3. Old regulations required some kind of supervision for reimbursement for the services of nurse anesthetists. This was payment that went to the hospital or facility who employs or contracts for nurse anesthetists and bills for their service. This is under Part A. Because this practice was inconsistent with the part B direct reimbursement to CRNAs, the AANA attempted to get this reversed. While signed by President Clinton, it was reversed by President Bush and reverted to a system where each state makes a decision on the issue. In other words the state can opt-out of the supervision requirement for part A Medicare.

4. Opt-out and TEFRA are related to MEDICARE REIMBURSEMENT and are no way practice issues. I have been in private practice in an (until recently) non-opt out state for over 25 years.

5. Making a reimbursement into a right to practice issue is simply false and should never be done. It is critical that you learn the difference.

Go to the AANA (www.aana.com (http://www.aana.com)) for the most up to date information. They have the best data on the topic, while others are trying to make it into a practice restriction/political/power issue.

Jan Mannino, CRNA, JD

TSICU83
10-23-2009, 10:22 PM
Yoga- Yes you do come across strong regarding these issues, but obviously it is something you are passionate about so I can understand that. I also concur with your comment about the spread of misinformation. It enrages mean when clinicians do this in the ICU setting and I don't want to be the one doing it regarding these practice issues. This is one of the many reasons I am trying to educate myself before I even begin school. So thanks for the continued input.

Mike- I thought that there must be this "hidden area" you speak of as i tried to access a link you had in a former post that was supposed to explain these things in detail and it blocked me out. Hopefully my interviews go well and I'll get that AANA number sometime soon so I can get myself all "edumacated".

EMTRNBSN
10-24-2009, 10:22 PM
Thanks Mike, Jan....

FANTASTIC! and truly appreciated....

:beerglass: :beerglass: :beerglass: