CRNA and anesthesiologist double billing question

[Ryan]

Rogue Dad, M.D. wrote:

Anesthesia for this is so simple it frankly doesn’t matter to me who does it — it’s all mask anesthesia and is only a few minutes.

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CRNA-bashing aside, that's a cavalier attitude.

[Zaphod]

Ryan wrote:

Rogue Dad, M.D. wrote:

Anesthesia for this is so simple it frankly doesn’t matter to me who does it — it’s all mask anesthesia and is only a few minutes. 

Click to expand…

CRNA-bashing aside, that’s a cavalier attitude.

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Is it really, cavalier? Come on, all anesthesia is a risk, a pretty darn low risk. There is no reason to be overly concerned with it in general. An acceptance and realization of these facts by a doctor that themselves know bad situations and bad actors occur and come in all degree types, its no cavalier.

These are gross over reactions to everyday things with a typical ultra conservative view of a doc.

Most of us engage in much more cavalier and dangerous activities with our kids that will have a much higher likelihood of harming them long term. Really have to put things in perspective.

 

[RogueDadMD]

Frankly this seems like defensiveness and combativeness to me. Calling it cavalier? Hardly.

If a CRNA can’t handle ear tubes independently then you might as well state they can’t handle anything. I’m not an anesthesiologist but I saw quite a few cases from the ENT and anesthesia side throughout my training. It was the shortest and most straightforward of any case I saw.

Complications can happen with any sedative or anesthetic. If a CRNA can’t be trusted to do anything other than the maintenance part of anesthesia than you basically are telling me they shouldn’t be in there at all.

Perhaps with your experiences that’s justified — I won’t speak to your experiences. But if someone has laryngospasm, usually you want two sets of hands regardless of whether all belong to an MD or not.

But what level of training would you equate a fully trained and experienced CRNA who only does peds to? A mid level resident? A fellow? Intern?

Sure I’m glad the anesthesia attending was somewhere around. He was probably overseeing multiple cases. As is common, just like during your anesthesia residency.

I’ve no way to know if he was there when induction happened. Maybe for billing he had to be, I don’t know the rules. Considering the entire case was probably 10-15 minutes I doubt he was there for induction AND emergence unless it’s absolutely required. Otherwise he may as well have stayed in the room and done it himself.

If he’s not around and laryngospasm happens it’s going to take a few minutes for him to even know and get to the room. A fully (and well) trained CRNA ought to know the first steps in those situations. If they don’t then yes that’s potentially a bad outcome, but if that isn’t part of the training then I don’t know how they have jobs at all.

I do lots of procedural sedation and supervise people doing it — I am not to the level of anesthesia obviously, but it’s part of my job to an extent. . I make sure they know enough to do the job, first rescue steps on their own, and to know when to get help if I am going to let them on their own for any part of it. But if they don’t know when to call for help or the risk is high then you shouldn’t walk away ever. And sometimes I don’t walk away.

Today I let an EM intern intubate a 31 year old patient (not a typo. 31 years old, septic, in my peds ER) whose initial BP was 40/15 on arrival to my ED.

And you bet I stood right next to him the entire time (but the BP was better when we intubated) and for awhile before and afterwards and was ready to knock his butt out of the way if there was any problem. But he nailed it.

[Bonez]

One of the hospitals I operate at on a regular basis has only CRNAs. The nearest medical center that actually has an anesthesiologist is about 30 miles away. Fortunately they are all very experienced and have worked at some of the larger hospitals in a nearby metropolitan area and the "lead" ones are professors at a major university CRNA program nearby. So far it seems to work out relatively well for a fair amount of elective orthopedics we do there. They do a bunch of regional blocks, spinals, etc and I've even had them do total IV anesthesia on patients that I'm neuromonitoring. I'd be a little more concerned if I had a patient with multiple poorly managed comorbidities maybe.

[Wiscoblue]

Yeah and I have had a Ortho PA inject my elbow and also my knee. I’m sure he did it just as well or maybe better than an Ortho and maybe I’ll ask for him to do it again in future. I’m not sure if the MD ortho has done any injections recently. When I had a vasectomy a few years ago, they told me that the urology PA does them all. The urologist will be in the building but he hasn’t done one in a while. Let’s keep handing off our jobs to the mid levels, guys. And let’s not be surprised when the mid levels start claiming to be your replacement. When I take my elderly mother with HTN and CHF to see her doctor, she is seen by a noctor. The noctor puts her stethoscope to her chest and I can clearly see it is turned to the bell instead of the diaphragm. But my moms real doctor has too many patients to see and the noctor is very nice and listens so patiently to my mom.

[RogueDadMD]

Wiscoblue wrote:

Let’s keep handing off our jobs to the mid levels, guys. And let’s not be surprised when the mid levels start claiming to be your replacement. When

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Valid but unrelated concern to the one brought up. Unless it’s why PoF is upset with my comment. This is a trend throughout medicine that is concerning in many possible ways. It doesn’t change the fact that whomever is doing the job needs the training  to do the job no matter the credentials

 

 

 

[Gasser75]

It’s funny how defensive anesthesiologists are versus CRNA’s. I’d be curious to see how much the ASA spends trying to tear us down. They need us to keep the medical direction scam going but they hate the fact that they can’t do it without us. There are plenty of good CRNA’s and anesthesiologists out there. And without CRNA’s underserved rural areas wouldn’t have any anesthesia.
The bill reflects medical direction. The CRNA half and the anesthesiologist half. No need to fight about who did the actual work.

[Wiscoblue]

Defensive? I think it is more about rural Hospital CEOs getting the pass though for hiring CRNAs and actually preventing docs from coming there. It’s also about urban Hospital admin “keeping down the cost of healthcare delivery” by having more NPs and PAs in the ER and the hospitalist department. Thereby keeping their bonuses intact. All the while the doc’s license is on the line as they supervise them and teach them and bail them out of difficult, avoidable situations.

[Gasser75]

The license on the line argument isn’t true for anesthesia. No such thing as “captain of the ship”. CRNA’s are liable for their actions. I don’t know about other midlevels.

[Zaphod]

Wiscoblue wrote:

Defensive? I think it is more about rural Hospital CEOs getting the pass though for hiring CRNAs and actually preventing docs from coming there. It’s also about urban Hospital admin “keeping down the cost of healthcare delivery” by having more NPs and PAs in the ER and the hospitalist department. Thereby keeping their bonuses intact. All the while the doc’s license is on the line as they supervise them and teach them and bail them out of difficult, avoidable situations.

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No need for anything to devolve into us vs. them talk. If you dont want to supervise or be on the hook I'd say so, thats understandable. Here in California, you're not on the hook for CRNA unless you give them anesthetic direction, which would be stupid since you'd then be on the hook.

There are 17 states total where CRNA practice independent and WI is one of them. I'd check to see your responsibility, it will likely depend on how things are billed, and your system, etc....

There seems to be plenty of money for salary and locums as it stands for both.

[Wiscoblue]

It is tough to separate the actions when you collaborate with or supervise/direct a mid level. The CRNA annual malpractice premium is less than half that of an anesthesiologist in my state. It can’t be that they are twice as safe as a doc?

I have sat in our ER, in the docs’ computer area and have seen a PA poke their head in and say to the ER doc ‘room 4 has a fever. Probably nothing but I’m going to send her to the floor and admit under the hospitalists to run some labs. And he says Fine, go ahead’. He hasn’t seen the patient or put his hand on their belly but right there he is liable for the action of that PA or whatever she missed. Do they charge on top of the PA’s charge or is that split too? Just curious.

[Zaphod]

Wiscoblue wrote:

It is tough to separate the actions when you collaborate with or supervise/direct a mid level. The CRNA annual malpractice premium is less than half that of an anesthesiologist in my state. It can’t be that they are twice as safe as a doc?

I have sat in our ER, in the docs’ computer area and have seen a PA poke their head in and say to the ER doc ‘room 4 has a fever. Probably nothing but I’m going to send her to the floor and admit under the hospitalists to run some labs. And he says Fine, go ahead’. He hasn’t seen the patient or put his hand on their belly but right there he is liable for the action of that PA or whatever she missed. Do they charge on top of the PA’s charge or is that split too? Just curious.

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Those things are systems issues, as is the topic in the original post. The reason malpractice is lower is simply they get sued less often because they are seen as traditional targets as MDs are. Thats where the big money is. This will likely change over time as they get further into independence and penetrance with concomitant exposure and increased suits that follow.

[Wiscoblue]

That makes sense. I just can’t understand why a doc can collect 50% of the payment but not be at least 50% liable.

[1gotgs]

Hi everyone! I am really late to this discussion, so forgive me if you already have the answer.

This is how it was explained to me.


Anesthesiologists are limited by the fed govt in terms on how many CRNAs they can work with at any given time, usually 4. And they have to be present for parts of the case and immediately avail for critical portions.

But what if there’s an emergency? Say up in OB for example. The anesthesiologist can’t be at all places at once. So what should we do? Can’t keep a bunch of people around in case of emergency. Not cost effective.

So the good people at the fed govt came up with a solution. If there is an emergency, the CRNA or md can break off and take care of it and still be in compliance. That causes md not immediately available or present during elective cases already under way.

So how do we bill for that? Not any real guidance on that, at least not that I know of, so the md and CRNA each were billed separately at 100%. So now the patient is responsible for 200% of their responsibility for the bill.

Well, over time anesthesiology and other hospital based specialties became “corporate”. These corporate groups hire providers and pay them salaries.

But the corporations use that “modifier” for all cases. Not just emergencies. So we all get double billed, even elective cases. Only private ins though, can’t get away with that Medicare, Medicaid or Tricare.

And it looks like now everyone is getting in on this strategy.

I once worked at a place where the anesthesiologists started all the ivs. I didn’t know why. I was an employee. Turns out there is a modifier for that. If the patient required an iv placed by the anesthesia service because it required “MD skill”, they could charge for the iv placement. Problem was, it was every patient. I heard a few called to complain and they took it off the bill.

You prolly have this figured out by now, but usually they never give us a proper explanation for why it was so expensive. If you fell into that group, I hope this provides some understanding.

[billy]

Hi everyone! I am really late to this discussion, so forgive me if you already have the answer.

This is how it was explained to me.


Anesthesiologists are limited by the fed govt in terms on how many CRNAs they can work with at any given time, usually 4. And they have to be present for parts of the case and immediately avail for critical portions.

But what if there’s an emergency? Say up in OB for example. The anesthesiologist can’t be at all places at once. So what should we do? Can’t keep a bunch of people around in case of emergency. Not cost effective.

So the good people at the fed govt came up with a solution. If there is an emergency, the CRNA or md can break off and take care of it and still be in compliance. That causes md not immediately available or present during elective cases already under way.

So how do we bill for that? Not any real guidance on that, at least not that I know of, so the md and CRNA each were billed separately at 100%. So now the patient is responsible for 200% of their responsibility for the bill.

Well, over time anesthesiology and other hospital based specialties became “corporate”. These corporate groups hire providers and pay them salaries.

But the corporations use that “modifier” for all cases. Not just emergencies. So we all get double billed, even elective cases. Only private ins though, can’t get away with that Medicare, Medicaid or Tricare.

And it looks like now everyone is getting in on this strategy.

I once worked at a place where the anesthesiologists started all the ivs. I didn’t know why. I was an employee. Turns out there is a modifier for that. If the patient required an iv placed by the anesthesia service because it required “MD skill”, they could charge for the iv placement. Problem was, it was every patient. I heard a few called to complain and they took it off the bill.

You prolly have this figured out by now, but usually they never give us a proper explanation for why it was so expensive. If you fell into that group, I hope this provides some understanding.

I hate how our overlords have figured out gaming the system, yet we get blamed. I just give the office number to any patient who asks about billing now, dont even bother attempting to explain it. Being hospital employed makes it even more frustrating.