2021 proves to be a havoc year for everyone, including the emergency medicine providers. They are being captured in a trap of profitability and revenue crisis right from the advent of 2021. As per the US survey, most emergency medicine physician groups usually have an average profit margin of less than 10%. In fact, the current pandemic situation adds more struggle to them by declining their volume. Apart from this, they are also awaiting the new federal legislation framed for patient’s protection from surprise medical bills, also known as “balance bills.” The surprising fact is that the impact of such legislation on emergency medicine reimbursement is still unpredictable.
However, The Centers for Medicare & Medicaid Services (CMS) has issued the Physician Fee Schedule (PFS) proposed rule, 2021, to impact emergency medicine reimbursement significantly.
The following are some highlights from the PFS rule, 2021:
2021 RVUs Increase for ED E/M Services
To protect the health safety net, CMS has been proposed to recognize the ED services intensity and maintain relativity between the new patient office codes and ED E/M codes. Even though 2020 has observed the ED codes increases of around 5% for code levels from 1-4, CMS has also agreed for ED relative value units (RUVs) increase for the code levels from 3-5 in 2021 as shown in the table:
|ED Visit Level||CPT Codes||RVUs (2020)||Proposed RVUs (2021)||% Increase|
2021 Conversion Factor Decrease
For 2021, CMS proposes a 10.6% decrease in Medicare PFS conversion factor from the last year, i.e., from $36.09 to $32.26. This CMS decision acts as a boon for urgent care (makes use of office codes for reporting) as this historic decrease provides scope for reimbursement increase. However, this decision will also increase the spending that will trigger the need for “budget neutrality adjustment” by the law. Due to such adjustments in the conversion factor, emergency medicine could see a 6% net decline. But, keeping in mind the current pandemic situation and the stress on the whole medicine house, the government may waive this neutrality requirement.
The following table shows the MIPS performance category weighting in the final score:
ED Continued Traction with Tele health Services
During the COVID-19 public health emergency, CMS is evaluating the codes that should remain permanent out of the temporary ones on the approved list of Medicare tele health services. In fact, CMS is proposing to keep ED E/M code levels from 1-3 on the approved list of telehealth services for the remaining year after this pandemic. However, CMS is not proposing for ED E/M code levels 4 and 5 because of too intense services to be performed regularly via tele health.
Preparing Tips for Emergency Departments:
Depending on the uncertainties that are lurking around for the emergency medicine providers, it’s crucial to:
- Understand the present condition of the emergency department financials thoroughly.
- Create a 2021 financials pro forma with an instance of one best and worst-case situation according to the uncertainties, including uninsured populations, federal balance billing legislation, reimbursement changes, etc.
- Deploy the services and technologies available to boost the revenue and the bottom line.
- Understand and formulate a plan as per the CMS rules that will be implemented after the pandemic.
- Urge legislators to waive off the budget neutrality requirements to avert the cuts that can lead to a 6% of net decrease for emergency medicine providers.
- Counsel legislators for structuring any new federal balance billing law keeping in mind the benefits of all, i.e., providers, patients, and payers.
- Be proactive in implementing strategies within regulatory constraints to cope up with the revenue challenge.
Emergency medicine physicians must ensure that every eligible insurance policy is timely and accurately billed. In fact, it can be rather more challenging to collect the payment from the financially at-risk patient population than from the insurance providers. The best option available in such a scenario is outsourcing the emergency medicine billing to the experienced 24/7 Medical Billing Services. Their experts start the process with the proper demographic verification that ensures the claims are clean and upfront. Moreover, it also efficiently create an invoice for the patients in case of an outstanding balance. Deductible monitoring enables timely billing of the patients. Once the deductible is satisfied, the payment can be captured. Together, these capabilities can bring in a dash of positivity in counteracting the proposed 2021 Medicare PFS cuts.