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This Just In
Insurer Ending Payments for Anesthesiologists Monitoring Routine Colonoscopies
OSD Staff
Publish Date: January 18, 2008   |  Tags:   Gastroenterology

Paying for Propofol
Aetna Halting Coverage for Anesthesia Monitoring for GI Scopes
Aetna, the third-largest U.S. health insurer, will no longer pay for monitored anesthesia care for routine colonoscopies as of April 1. MAC typically adds $300 to $1,500 to the cost of a screening, says Aetna spokeswoman Susan Millerick. In a letter sent to physicians last month, Aetna says that "conscious sedation is a safe and well-tolerated choice for most patients undergoing GI endoscopy. There is no generally accepted evidence demonstrating that average-risk patients require MAC for routine GI endoscopy. Therefore, we will cover MAC only for patients undergoing GI endoscopy with sedation-related risk factors."

Those exceptions include if the patient is assessed at an ASA score indicating an increased risk of complications (P3 to P5), pregnant, 18 years of age or younger, 65 years or older or in danger of airway compromise, such as by being morbidly obese or having sleep apnea.

Aetna notes in the letter that its clinical policy is consistent with the following 2004 statement on sedation for performing GI endoscopic procedures jointly issued by the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy: "The routine assistance of an anesthesiologist/anesthetist for average-risk patients undergoing standard upper and lower endoscopic procedures is not warranted."

Aetna's revised guidelines follow similar actions by other insures. Humana announced last July that it was no longer going to cover anesthesiologist or anesthetist assistance for standard endoscopic upper or lower GI procedures performed on average-risk patients. In 2006, WellPoint updated its guidelines to say that it was unnecessary to use general anesthesia during endoscopic procedures, so there was no need to pay for the routine use of these ancillary anesthesia service.

— Nathan Hall

Anesthesia Awareness on the Big Screen
The movie Awake, a mystery revolving around a patient suffering anesthesia awareness during a heart transplant, made its way to theaters nationwide on Nov. 30. It was met by mixed reviews, low box office numbers and earnest healthcare reporters explaining surgical sedation to John Q. Patient. The New York Times described the long-delayed, 78-minute film as "loopy" ("The sterility of the operating room is repeatedly compromised," the Times tsk-tsked) and E! Online griped, "Awake poses as a medical thriller, but it ends up being a dull dive into absurdity." Roger Ebert, however, found it "a surprisingly effective thriller" ("Accuracy is not the point," he wrote in the Chicago Sun-Times. "Suspense is.") and the Washington Post's reviewer saw "a pleasing if negligible diversion," noting that "the film seems to find interesting ways to combine surgical footage with actors."

— David Bernard

Barcoded Sponge System
Scanning Is an Extra Step to Prevent Retained Objects
In addition to counting sponges by hand, the OR staffers at Loyola University Medical Center in Maywood, Ill., scan the small square barcode that is heat-sealed on each sponge as an extra check. If the number of sponges used doesn't equal the number of sponges removed, they hear about it from their computerized scanner.

Since the staff frequently performs complicated cases that can involve hundreds of sponges, it wasn't hard to imagine a retained object, says Jo Quetsch, RN, clinical director of surgical services. The idea to use barcodes came from a review of quality improvement initiatives for patient safety, says Ms. Quetsch. "There haven't been any changes in the standards for counting in a long time," she says.

The patient's identification number and the badge number of the staff member who is maintaining the count are scanned into the device before the procedure, says Perry Drake, senior manager of media relations at Loyola. Each sponge has a unique barcode so the scanner will keep a running count of how many are in use and how many have been removed. It will make a sound and display a warning on the screen if the same sponge is scanned twice or one is missing.

Staffers still do three hand counts (one when the patient is receiving the sponge, another when the surgeons start closing the incisions and a last count at the end of closing), says Ms. Quetsch, so the barcode system serves as an extra precaution. "Right now it probably adds an extra five to 10 minutes per case," she says.

— Nathan Hall

Surgeons to the Stars Pay $700,000 in Stark Law Settlement
James Andrews, MD, and Lawrence J. Lemak, MD, two well-known orthopedic surgeons whose patients have included Michael Jordan, Roger Clemens and Donovan McNabb, agreed last month to pay the U.S. Department of Justice $700,000 to settle a Medicare and Medicaid fraud case.

The Department of Justice alleges that the surgeons violated the Stark Law in 2003 when they referred patients to HealthSouth Corp. rehabilitation facilities while serving as well-paid medical directors for HealthSouth. For its part, HealthSouth will pay $14.2 million in the case, which also includes an unnamed group of physicians in Los Angeles. Dr. Andrews will pay $450,000 and Dr. Lemak will pay $250,000.

Drs. Andrews and Lemak, who were partners at the time, were medical directors with HealthSouth from 1988 through June 2003. The government says that they were paid above market value. Dr. Lemak denies that his salary was above fair market value. It should not be considered a kickback, says the physician's attorney, John T. Brennan of Washington, D.C. "Dr. Lemak's settlement is a Stark-related matter."

Dr. Andrews wasn't available for an interview, says his spokesman, Lanier Johnson.

"Medicare beneficiaries deserve their physicians' unbiased judgment regarding their treatment, free of improper financial influences," says Jeffery S. Bucholtz, acting assistant attorney general for the Justice Department's Civil Division, in a statement. "[This] settlement sends a loud message to healthcare providers that we will strongly enforce the Anti-kickback Statute and the Stark Law to deter such conduct."

— Kent Steinriede

CON Battle Rages in Georgia
Community Hospitals' Lawsuit Targets General Surgery ASCs
The 59 members of the Georgia Alliance of Community Hospitals filed suit last month to negate a ruling by the Georgia Board of Community Health that would let general surgeons build freestanding ASCs without first going through the state's certificate of need process.

The board voted last month to classify general surgery as a single specialty, paving the way for general surgeons to own and operate outpatient surgery centers. Under the state's Department of Community Health regulations, single-specialty groups are exempt from applying for a CON and committing to a minimum level of indigent care before building a new facility. The board also approved a resolution asking the Georgia General Assembly to create legislation that would require exempted ASC owners to report their charitable care utilization to the state.

"As the Department of Community Health and its board members know full well, the new

general surgery rule flies in the face of multiple court decisions and is a naked and illegal attempt to override the will of the General Assembly of Georgia," says Monty Veazey, president of the Georgia Alliance of Community Hospitals. "DCH has been publicly and repeatedly advised by its own legal counsel that it lacks the authority to make this rule change."

Georgia Gov. Sonny Perdue called for an overhaul of the state's healthcare regulations during the 2007 General Assembly, but his overhaul bill failed. The Georgia DCH then decided to rule on the CON portion of the overhaul bill, despite claims from opposition that only the General Assembly has jurisdiction over such matters.

— Daniel Cook

In the Know

  • Hot Pic Puts Doc in Hot Water. Surgeon Adam Hanson, MD, is no longer operating at the Mayo Clinic Arizona after admitting to using his cell phone's camera to snap a picture of a patient's tattooed penis, says a Mayo Clinic spokeswoman. Sean Dubowik, 37, who went to the Mayo Clinic for gallbladder surgery, reportedly has the phrase "Hot Rod" tattooed on his genitalia. "The photo was displayed to others internally but to our knowledge not shared in any other fashion," says Denis Cortese, MD, the Mayo Clinic's president and CEO.
  • Brachytherapy Billing. Beginning this month, ASCs may bill and receive separate Medicare payments for brachytherapy sources under the new Medicare ASC payment system. Also, ASCs that furnish brachytherapy services may take full advantage of expanded coverage for brachytherapy sources without any Stark law concerns, says the ASC Association. There had been concerns whether the Stark Law would prohibit an ASC (owned by physicians who order brachytherapy) from billing Medicare for brachytherapy sources furnished to patients referred by those physician-owners, but Medicare has extended the Stark implant exception to brachytherapy sources.
  • Audit: 4 N.Y. State ASCs Collected $8M in Overpayments. Audits released last month by New York's state comptroller say four of the state's largest ASCs waived out-of-pocket costs to their patients, then submitted out-of-network claims to an insurer that pays considerably more than it would a participating provider. Auditors say this went on from January 2001 through December 2006, costing taxpayers $8 million. The patients who were treated at these facilities all saw physicians who participated in the insurer's plan, yet none of the surgical facilities were participating providers in the plan.