Regulatory Requirements for Anesthesiologists
As is the case with other medical professionals, anesthesiologists must comply with a variety of regulatory requirements in their practices. Consequently, anesthesiologists incur significant costs to ensure compliance [1]. It takes significant resources and effort to address all regulatory requirements for anesthesiologists, such as administrative infrastructure, nonclinical staff charged with handling human resources and billing, employee benefits, and malpractice insurance coverage [1]. While enumerating all of the requirements that apply to anesthesiologists would consequently be a difficult task, this article will highlight some of the regulations that govern anesthesiologists in the United States.
To begin, the Medicare Quality Payment Program (QPP) requires Merit-Based Incentive Payment System-eligible (MIPS) providers to satisfy reporting requirements during each performance year [2]. Providers can satisfy this requirement through one of three options: traditional MIPS reporting, the Alternative Payment Model (APM) Performance Pathway, or MIPS Value Pathways [2]. Anesthesiologists may have to report on measures pertinent to their specialty, such as multimodal pain management, perioperative temperature management, and anesthesiology smoking abstinence [3]. Across medical specialties, providers tend to consider these requirements “very or extremely burdensome” [4].
Recent additions to regulatory requirements are related to the elimination of surprise billing, which can occur when a patient receives out-of-network medical services [5]. Anesthesia services tend to be a major source of surprise billing which can be explained by the fact that patients are not usually the ones who choose their anesthesiologist, and many facilities contract independent anesthesia groups to provide services [5]. Both state and federal legislation target this problem. New York, California, and Florida have passed surprise-billing laws that have reduced the out-of-pocket costs that patients pay to anesthesiologists working in ambulatory surgery centers and outpatient departments [5]. Furthermore, the federal No Surprises Act has addressed the issue by “creat[ing] a mechanism for physicians and health insurance companies to address the bills for medical services” [6]. Unfortunately, many practitioners as well as the American Society of Anesthesiologists have raised criticisms of how the Act and the dispute resolution process has been implemented.
Another aspect of the No Surprises Act is its Good Faith Estimates (GFE) requirement [7]. This provision requires anesthesiologists to make an honest effort to generate a cost estimate for self-pay and uninsured patients [7]. They must try to account for all charges that a patient could reasonably expect to incur over the course of treatment [7]. Of course, the Act recognizes that improbable or unforeseen events may transpire, but anesthesiologists are not in contravention of the Act if they do not anticipate those events when calculating the GFE [7].
Audits comprise a final example of regulatory requirements that apply to anesthesiologists. The purpose of audits is to identify suspected provider fraud and abuse [8]. The Office of Inspector General (OIG) of the Department of Health and Human Services often targets anesthesia groups [8]. Among the other requirements already discussed, two additional common issues that are assessed during audits are medical necessity —namely, whether a patient’s conditions warranted anesthesia services— and anesthesia modifiers —meaning whether medical providers used the accurate anesthesia modifier code to describe the service that they provided [8]. To ensure that audits go smoothly, anesthesia groups should be proactive: administrators should put procedures in place and employ staff members to ensure compliance with regulatory requirements [8].
As costly as compliance may be, anesthesiologists must account for these and other regulatory requirements to run a successful anesthesiology practice, avoiding fines and other punitive measures, and, most importantly, promoting patient health.
References
[1] Z. Deutch, “The Current and Future State of Anesthesiology: Good, Bad, or Indifferent?,” ASA Monitor, vol. 87, pp. 13-15, July 2023. [Online]. Available: https://doi.org/10.1097/01.ASM.0000945076.05386.b8.
[2] “Traditional MIPS Overview,” Quality Payment Program. [Online]. Available: https://qpp.cms.gov/mips/traditional-mips.
[3] “MIPS Quality Performance Category (2023),” American Society of Anesthesiologists, Updated May 1, 2023. [Online]. Available: https://www.asahq.org/advocating-for-you/qpp/quality.
[4] D. Muoio, “Prior authorization and other regulatory burdens have increased since last year, practices tell MGMA,” Fierce Healthcare, Updated November 13, 2023. [Online]. Available: https://www.fiercehealthcare.com/providers/practices-say-prior-authorization-and-other-regulatory-burdens-have-increased-last-year.
[5] Ambar La Forgia et al., “Have Surprise-Billing Laws Lowered Health Care Prices? The Case of Outpatient Anesthesia,” The Commonwealth Fund, Updated August 16, 2021. [Online]. Available: https://www.commonwealthfund.org/publications/journal-article/2021/aug/have-surprise-billing-laws-lowered-health-care-prices.
[6] Amanda Cate, “Surprise Medical Bills / Out-of-Network Payment,” American Society of Anesthesiologists, Updated March 2022. [Online]. Available: https://www.asahq.org/advocating-for-you/surprise-medical-bills.
[7] Thomas W. Greeson, James F. Hennessy, and Andrew Hayes, “No Surprises Act Good Faith Estimates What They Are and When You Need Them,” Reed Smith, Updated February 8, 2022. [Online]. Available: https://www.healthindustrywashingtonwatch.com/2022/02/articles/department-of-health-and-human-services/no-surprises-act-good-faith-estimates-what-they-are-and-when-you-need-them/.
[8] V. Myckowiak, “The Smart Anesthesia Group’s Guide to Defending a Payer Audit,” Anesthesia Business Consultants, Updated Fall 2017. [Online]. Available: https://www.anesthesiallc.com/publications/communiques/97-communique/past-issues/fall-2017/1070-the-smart-anesthesia-group-s-guide-to-defending-a-payer-audit.