CRNAs Billed for Few Selected Chronic Pain Procedures, Most of Which Were in Rural Areas

From 2009 through 2012, CRNAs billed Medicare FFS for a small share  of our selected chronic pain procedures, while pain physicians and other  physicians billed for the largest shares. The  share billed by NPs, PAs, and CRNAs combined grew from 1.4 to   2.6 percent, with CRNA’s billing for less than ½ of 1 percent of all chronic  pain procedures in each year. Of All CRNA-Billed Chronic Pain Procedures from 2009 through 2011, Most Were Rural; In 2012, Urban CRNAs Were Dominant

Although the number of selected chronic pain procedures billed by all  rural providers increased somewhat from 2009 through 2012, the number  of procedures billed by CRNAs in rural areas declined over the period. Of all CRNA claims for selected procedures, the share  submitted by providers in rural areas fell from 66 percent in 2009 to   39 percent in 2012; meanwhile, the share of selected procedures  nationwide billed by all rural provider types was roughly 11 percent in  both 2009 and in 2012. 3.) After Noridian Began Denying CRNA Claims, Changes in the Number of Chronic Pain Procedures Billed Varied across Three Selected States

In mid-2011, Noridian began denying certain chronic pain management  services that were billed by CRNAs and maintained this policy through  2012. 6): allowed payment to CRNAs for all selected procedures in 19 states, allowed payment to CRNAs for a subset of selected procedures in   30 states and the District of Columbia, and denied payment to CRNAs for all selected procedures in the  remaining state. In the 30 states and the District of Columbia where MACs allowed  payment to CRNAs for only certain chronic pain procedures, MAC  payment policies indicated substantial variation in the specific procedures  that can and cannot be billed. Three MACs Took Steps to Implement CMS Policy, While Remaining Six Did Not Revisit Payment Policies for 2013

Three MACs took steps to implement CMS’s 2013 rule on CRNA  payment and updated their CRNA payment policies, when necessary. CMS officials told us that they rely on MACs to determine whether  CRNAs are allowed to provide specific services by reviewing each state’s  CRNA scope of practice laws. Most MACs reported  challenges interpreting state scope of practice laws to make  determinations about which services CRNAs are allowed to provide,  noting that state scope of practice laws are generally vague and lack  details about which specific services CRNAs can perform. Two MACs assumed that Medicare’s rule requiring physician supervision  of anesthesia services provided by CRNAs in hospital and ASC settings  applied to chronic pain services in all settings; this assumption has  potential implications for CRNA billing of chronic pain services. By applying this rule to office  settings, these MACs may have unnecessarily restricted the services for  which CRNAs in 10 of the states under these MACs’ jurisdictions are  allowed to bill. Recommendations for Executive Action

In order to ensure consistent implementation of CRNA payment policy,  we recommend that the Administrator of CMS (1) provide specific  instructions to MACs on how to determine coverage with reference to a  state’s scope of practice laws, including instructions on how to proceed if  the state scope of practice laws are not explicit, and (2) clarify the  applicability of the CRNA supervision rule to payment for CRNA-provided  chronic pain management services. Analysis of Medicare Claims Data

To determine trends in billing for the selected procedures, we analyzed  100 percent of Medicare fee-for-service (FFS) paid claims from 2009  through 2012.
Why GAO Did This Study

Chronic pain costs the nation about $600 billion each year, a quarter of which is borne by Medicare. One MAC, Noridian Healthcare Solutions (Noridian), began denying CRNA claims for certain chronic pain services in 2011, citing patient safety concerns. CMS issued a rule, effective January 2013, clarifying that CRNAs can bill Medicare for “any services that a [CRNA] is legally authorized to perform in the state in which the services are furnished,” including chronic pain management services. GAO was asked to review Medicare's payment policy regarding the provision of chronic pain management services by CRNAs. This report examines, among other things, (1) trends in Medicare provider billing for selected chronic pain procedures; (2) in which states MACs allowed payment for selected procedures billed by CRNAs as of early 2013; and (3) how MACs implemented the payment policy. To do this, GAO selected seven categories of chronic pain procedures, in consultation with pain care experts. GAO analyzed Medicare claims data from 2009 through 2012, by provider type and geography. To determine which MACs allow CRNA payments and how MACs implemented CMS's policy, GAO interviewed medical directors at all nine MACs.

What GAO Found

From 2009 through 2012, certified registered nurse anesthetists (CRNA)—a type of advanced-practice nurse specializing in anesthesia care—billed Medicare fee-for-service (FFS) for a minimal share of selected chronic pain procedures, less than ½ of 1 percent of these procedures in each year. Physicians without board certification in pain medicine billed for the majority of selected procedures each year, while pain physicians consistently billed for roughly 40 percent of selected procedures. Furthermore, although the number of chronic pain procedures billed by all rural providers increased from 2009 through 2012, the number of procedures billed by rural CRNAs declined over the period. Of all CRNA claims for selected procedures, the share billed by CRNAs in rural areas fell from 66 percent in 2009 to 39 percent in 2012.
As of early 2013, Medicare Administrative Contractors (MAC)—entities that pay medical claims on behalf of Medicare—allowed payment to CRNAs for all selected procedures in 19 states, allowed payment for a subset of selected procedures in 30 states and the District of Columbia, and denied payments for all selected procedures in 1 state. Where MACs allowed payment to CRNAs for only certain procedures, payment policies indicated substantial variation in the specific allowed procedures.
Three of the nine MACs took steps to implement a Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) rule, effective January 2013, that defers to state scope of practice laws to inform coverage for CRNAs. CMS relies on MACs to review each state's CRNA scope of practice laws. However, most MACs reported difficulty interpreting state scope of practice laws regarding the services that CRNAs are allowed to provide; MACs noted that state scope of practice laws generally lack detail on which specific services CRNAs can perform. In addition, two MACs assumed that Medicare's rule requiring physician supervision for anesthesia services provided by CRNAs in hospital and ambulatory surgical center settings applied to chronic pain management services provided in all settings; this may have unnecessarily restricted the services for which CRNAs are allowed to bill in certain states.

What GAO Recommends

GAO recommends that CMS provide specific instructions to MACs on (1) how to determine coverage with reference to a state's scope of practice laws, and (2) the application of the CRNA supervision rule. HHS concurred with these recommendations.