Tip: The cart goes behind the horse!
By Jean Covillo, DNAP (C), CRNA
Many studies exist that address salaries and other compensation benefits associated with the CRNA profession when practicing as an employee or an independent contractor.1 But no published studies exist that address CRNA-led practices that receive compensation through direct billing reimbursement. The percentage of CRNAs who directly bill “fee for service” is unknown and reimbursement benchmarks have never been established. Previous methods used to identify and differentiate this practice subset have been obscured and distorted through the widespread use of the QZ modifier. Historically the independently practicing CRNA could easily be identified by tapping into the Medicare claims databases (or other large claim databases) and separating out claims submitted with the QZ modifier, signifying the procedure was performed by a non-medically directed CRNA. Nowadays, QZ claims no longer clearly represent independently practicing CRNAs or those participating in “fee for service” billing. Instead, they may more accurately reflect the number of claims reclassified and submitted by physician-led practices that “failed medical direction”.2-5
Hospitals and surgery centers have increasingly turned to CRNAs for safe, cost-effective alternatives to traditional physician-led anesthesia delivery models. Anesthesia delivery by CRNAs is oftentimes the only viable economic option for facilities operating fewer than four rooms where case volume reimbursement is insufficient to support an anesthesiologist directing multiple CRNAs. Instead of paying stipends to make up for the increased operating expense, facilities are outsourcing the anesthesia services to CRNA groups equipped in all aspects of care, including the complexities associated with anesthesia billing.6-10 Consequently, more and more CRNA-led groups are seeking participation with commercial payers (payers) as “in-network” providers.
The commercial insurance industry is a highly competitive, profit-driven enterprise that fully relies on the longstanding practice of transactional secrecy and non-disclosure agreements when negotiating provider rates. The original intent behind these secrecy laws was to minimize exposure to “price-fixing” practices employed by large groups of providers leveraging higher payer rates. In reality, the consequence of these laws has left specific provider types like the CRNA vulnerable. By creating a system shrouded in secrecy, providers are unable to reasonably gauge the fair market value as compared to peers, leaving specific providers vulnerable to exploitation and discrimination with no means to show evidence this is occurring. Reductions in CRNA reimbursement rates based purely on licensure of the provider rather than performance and quality, unfairly disadvantages the CRNA from freely competing in the healthcare market.
In an effort to overcome these secrecy regulations, the ASA has performed yearly reimbursement rate surveys for its physician members, giving valuable insight critical for contract negotiation. CRNA-led practices do not participate in these surveys.11Consequently, the commercial rates published are only reflective of physician-led practices and offer no distinction or comparison to rates negotiated by practices led by CRNAs .
Future study will focus on correcting this deficiency through database development specific to CRNAs who contract directly with commercial payers to provide “fee for service” anesthesia delivery under the QZ modifier. Since the number of CRNAs who fit into this subset is currently unknown and no database is available that identifies CRNAs with these characteristics, a pilot study will be initiated aimed at database development. This database will formulate the population sample necessary to accurately study CRNA reimbursement while establishing reimbursement benchmarks specific to CRNAs and identifying and resolving commercial insurance policies affecting parity in payment under the QZ modifier. To participate in this project click on the link. CRNA Billing Population Database
- American Association of Nurse Anesthetists 2020 Compensation and Benefits Survey (2019 Data)
- Quraishi J, Jordan L, Hoyem R. Anesthesia Medicare Trend Analysis Shows Increased Utilization of CRNA Services. AANA Journal. 2017;85(5):375-383. doi:https://www.masscrna.com/assets/docs/qz_article.pdf
- Miller TR, Abouleish A, Halzack NM. Anesthesiologists are affiliated with many hospitals only reporting anesthesia claims using modifier QZ for Medicare claims in 2013. A&A Case Rep. 2016;6(7):217-219 DOI: 10.1213/XAA.0000000000000223
- Sun E. Does the Modifier “QZ” Accurately Reflect Independent Nurse Anesthetist Practice: And Why Does It Matter? A & A Case Reports. 2016 Apr;6(7):220-221. DOI: 10.1213/xaa.0000000000000254
- Byrd JR, Merrick SK, Stead SW. Billing for Anesthesia Services and the QZ Modififer: A Lurking Problem. ASA Monitor. 2011;75(6):36-38. https://pubs.asahq.org/monitor/article-abstract/75/6/36/4781/Billing-for-Anesthesia-Services-and-the-QZ?redirectedFrom=fulltext. Accessed Dec 4, 2020.
- Massie, MB. Determinants of Hospital Administrators’ Choice of Anesthesia Practice Model.Virginia Commonwealth University.2017; https://core.ac.uk/download/pdf/84403806.pdf. Accessed Dec.4, 2020.
- The Lewin Group, prepared for American Association of Nurse Anesthetists.Update of Cost Effectiveness of Anesthesia Providers: Final Report Falls Church, VA: Lewin Group Inc May 2016. http://www.lewin.com/content/dam/Lewin/Resources/AANA-CEA-May2016.pdf. Accessed December 6, 2020.
- O’Neill NA (2017) Anesthesia Policies- Increasing Costs with No Improvement in Value. J Healthc Commun. 2:66. doi: 10.4172/2472-1654.100107
- Quintana, J.F., Jones, T., & Baker, K. (2009). “Efficient Utilization of Anesthesia Practice Models: A Cost-Identification Analysis.” Unpublished manuscript.
- Hogan PF, Seifert RF, Moore CS, Simonson BE (2010) Cost effectiveness analysis of anesthesia providers. Nursing Economics 28: 159-169.
- Stead S, Merrick S. ASA Survey Results for Commercial Fees Paid for Anesthesia Services – 2019. ASA Monitor October 2019, Vol. 83, 70–77. https://pubs.asahq.org/monitor/article/83/10/70/108371/ASA-Survey-Results-for-Commercial-Fees-Paid-for. Downloaded December 27, 2020.