ACP members can influence policy on Medicare's fee schedule

Over the next six to 18 months, ACP will ask randomly chosen members to complete surveys to influence Medicare reimbursement for services common to internal medicine, much as it did three years ago during the last survey cycle. Survey results will become the primary source of data Medicare uses to determine reimbursement, so it is essential that ACP members complete surveys when they receive an invitation by e-mail.

This article, similar to one that appeared in ACP Internist three years ago, outlines what members can expect as part of the process.

The Centers for Medicare and Medicaid Services (CMS) bases payment for Medicare Part B physician services on the resource-based relative value scale (RBRVS), reimbursing services based on the resources and costs involved in furnishing all medical services relative to each other.

CMS expresses these costs as relative value units (RVUs). The agency assigns three different RVU components for each service based on:

• the work a physician must do,
• administrative overhead expenses involved in providing the service, and
• the cost of professional liability insurance.

To compute the payment to a physician, all three relative value components are further adjusted to account for geographic differences in cost. Their sum equals the total RVU for a service. Finally, CMS sets a conversion factor expressed in dollars to derive the actual payment amount.

Q: How does ACP provide input to the relative values Medicare assigns to services?

A: ACP and other physician organizations engage CMS directly regarding RBRVS maintenance and Medicare payments. There are two major groups of physicians involved in the Relative Value Update Committee (RUC) process: the RUC members and the specialty advisors. The American Medical Association, in collaboration with physician specialty organizations, convenes a committee of physicians that makes RVU recommendations to CMS. These physicians are responsible for objectively voting on the relative values of medical services, without regard for their own medical specialty. Specialties appoint these RUC members; they are joined by a broader group of specialty organizations in appointing physicians (called advisors) who represent their respective specialties and serve in an advisory role to the process.

Q: How does the RUC make recommendations to CMS?

A: The RUC generally makes recommendations on services before they first appear in the Current Procedural Terminology (CPT) codebook. It also makes recommendations on services the agency identifies for an accuracy assessment, as part of a statutorily mandated review done every five years.

Q: What information is collected?

A: The RUC uses standard survey instruments that are based on the type of service. The survey uses a seven-part form that asks for answers about the amount of time, mental effort, medical judgment and patient risk involved in a particular service. It also asks the physician to compare the intensity of these activities to other medical services and procedures. Physicians' responses provide necessary insight to the evolving work and resource demands of medical practice.

Q: How is it collected?

A: Specialty organizations conduct the RUC surveys. Each specialty decides which services to survey based on how commonly its members perform them. For example, this year ACP will survey members on the newly identified work and direct overhead involved in outpatient care.

The process works as follows:

• ACP will contact selected members requesting that they complete a survey on the services that are under review;
• ACP coding and payment experts will use the survey data and other pertinent factors to decide on the College's relative value recommendations;
• The College's RUC advisor will present those recommendations to the RUC to convince their peers that the recommendations are appropriate; and
• The RUC, with that input from its advisory committee, will decide on a final recommendation that it then transmits to CMS.

Q: Why are ACP's surveys important to the process?

A: CMS accepts the great majority of the RUC's recommendations; this is based largely on the notion that they reflect a collective decision by a diverse group of physicians as to the relative value of one service compared to all others. Thus, the RUC process requires participation from all specialties.

All physicians are best served when all specialties actively convey the work and overhead involved in their respective, commonly furnished services. Since the surveys are the primary source of data used to determine RVUs, it is essential that ACP members complete surveys so that the College has the information to optimize its participation.

Since many commercial health insurers, Medicaid and state workers' compensation programs use the RBRVS as the basis of their own fee schedules, ACP's involvement has implications beyond Medicare.

Q: Who is chosen to participate in a RUC survey?

A: In almost all cases, the survey samples are chosen from among the specialty society's membership rolls. While the RUC provides some discretion in how specialties identify survey participants, ACP typically selects a random sample.

If you are asked to complete a survey, it is vitally important that you do. ACP needs a strong response rate and reliable data so that the College's recommendations survive the scrutiny of RUC and CMS review. It is also important to remember that these surveys are the primary mechanism for internists to have an expert voice in determining RBRVS values that are used by Medicare and other payers.

Q: Is the government looking at my answers?

A: CMS will see aggregate statistical results, but not individual responses; nor will the agency receive personal or demographic information. While the RUC reserves the right to review actual completed surveys, all personal information is kept confidential.

Q: Is there a way for me to learn how to answer a RUC survey?

A: Yes, there is an online tutorial that explains how to complete a RUC survey form. You can view the tutorial at ACP's Running a Practice section online.

Please contact Debra Lansey at (800)-523-1546, ext. 4544, or by e-mail if you are interested in participating in RUC surveys. ACP will maintain a list of self-identified pool of respondents.