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2020 CMS Final Rules: Q&A with Jim Hugh

By Tammy McCausland and Jim Hugh

In this Q&A, Jim Hugh, senior vice president of American Medical Accounting and Consulting, Inc., (AMAC) shared his thoughts on the 2020 CMS Final Rules.

Thoughts on the New 2020 CMS Final Rules:


Q: What are the changes in payment rate for 2020?

A: The basic changes for the hospital (OPPS) for Medicare patients will be somewhere between a 3 percent and 4 percent increase overall for the average department. The Medicare physician fee schedule will be a slight increase for both the professional and technical allowables with an increase in the professional component of 0.006% , for technical payments a 0.005% increase.

Q: Do you know why those changes took place?

A: Last year, there were zero increases in the hospital payment rates, and that was probably one of the first times I have seen that occur. Usually, it’s anywhere between a 1 percent and 5 percent increase every year. With no increases in 2019, I think CMS was making up for that this year by doing an increase in the actual payment rates for hospitals; the physician rates on the professional side are generally increasing slightly, and the technical decreases slightly each year.

Q: Can you explain what CMS did for hospitals regarding general supervision?

A: We have been proponents of one general supervision rule for a very long time. Rural hospitals and hospitals that are underserved with radiation oncologists or physicians that have 100 beds and less been under the general supervision rules for over a decade. They’re exempt from the supervision rules, and there really haven’t been any issues.

CMS had two regulations, one for hospitals with 100 beds and under, and one for hospitals with 101 beds and higher, under direct supervision for therapeutic treatment procedures. We were very excited that CMS decided to do it across the board—general supervision for all hospitals.

This is misleading because general supervision doesn’t mean that the radiation oncologist doesn’t have to come to the console for your SRS radiosurgery cases. It does not preclude the radiation oncologist from coming to the console for SBRT cases. Also, the radiation oncologist has to be there for your brachytherapy procedures, simulations, etc.

It’s only really for standard treatments. Simple, intermediate, and complex standard treatments. IMRT treatments. Continuing physics because the physician has nothing to do with continuing physics. It’s checked by the physicist only. The therapists treat the patients, and most states have laws where physicians cannot treat a patient, only a therapist can, so these are the scenarios, and possibly also guidance procedures could be billed technically without the physician being there, but these are procedures that are very simple in nature and do not require the input at all of a physician at the time.

Now, scenarios that I could see this working would be if a physician was at a hospital and had to attend a Gamma Knife procedure and was not available. The hospital could continue treating the patients for the 30 or 40 minutes the physician is at a Gamma Knife procedure. Or, the physician is at a brachytherapy procedure in the operating room. The hospital would still be able to bill for these procedures.

Another good example would be if the therapist started treating patients at 7:30 a.m., and the physician was involved in an accident or something happened. The staff could treat those patients until the physician comes to the hospital perhaps an hour or two later.

These are the basic Medicare general supervision rules that I think will stop a lot of whistleblower lawsuits and stop a lot of attorneys from getting involved where there really was no situation.

I think that we have to step back and take a look at Aetna, United Healthcare, Cigna and Blue Cross Blue Shield’s requirements about physicians being present, and do they accept Medicare guidelines and general supervision?

The general supervision rule is not a really big deal, as a lot of the major institutions I’ve contacted have said they don’t really care what the general supervision rules are for Medicare. They’re going to stick with their own hospital regulations, where a radiation oncologist must be present.

Q: What is the rule for people who are not getting treated through Medicare?

A: That point would have to be answered by each individual hospital contract—your Blue Cross Blue Shield contract, your Cigna contract, your Aetna contract, etc. Most importantly, this is only for hospitals. This rule has nothing to do with ambulatory surgery centers or privately owned, corporately owned, freestanding centers. Freestanding centers and ambulatory surgery centers still must have a physician inside the radiation oncology treatment facility or the ambulatory surgery center.

Q: When do we stop using the old Medicare numbers?

A: As everyone knows, CMS stopped using social security numbers for their Medicare part A and part B cards that patients present upon registration at the cancer centers, and they have now the very long alphanumeric number system. As of January 1, 2020, Medicare will no longer process claims using the old Medicare social security numbers.

Q: Should HIPAA risk assessments be done yearly?

A: HIPAA has a security part of the actual program, that I believe it went into effect January 1, 2019. Our company, for example, went through our risk assessment at the end of 2018 to determine how we keep our information private, how we prevent hackers from coming into our system, and maintain security items. Each doctor’s office, hospital and freestanding center will hire an outside company to do an evaluation of, what are their security risks. Even a solo practice physician must have an annual risk assessment.

Q: Do you think a lot of people realize that the assessment* has to be done annually?

A: I don’t think a lot of people know it’s required. It’s on the CMS website. If you go to and type in ‘risk assessment’, they give you the myths of risk assessment. They tell you how to set up a program. They tell you what the penalties are for not doing it. I think they can take away 4 percent of your income if you don’t do a risk assessment. All the CMS final rules and regulations are available on the website.

Q: Where do you see things going over the course of this year and into next year?

A: The Affordable Care Act is being attacked again, and the Supreme Court refused to hear the appeal. In 2020, I it will probably be decided whether they’re just going to dissolve The Affordable Care Act totally or just remove parts of it that are unconstitutional as found in federal court. I think we’re going to find portions of the Affordable Care Act going away this year, and that may affect the Centers for Medicare and Medicaid Innovation, the CMMIs. If the CMMI portion is removed, then we will may not see the alternative payment models coming into fruition in 2021.

The CMS final rule for the alterative payment model was not released. We were all looking forward it to be released in November, then December, and I thought for sure it would be in January, but with the new CMMI director put into place less than two weeks ago, I don’t see the final rule coming out until maybe the middle of this year, and then maybe going into effect in 2021/2022. Of course, we have an election coming up in November, and that may change everything going forward after 2021.

* You can read “Top 10 Myths of Security Risk Analysis.”


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