Comments of the MMS Regarding Proposed Amendments to 130 CMR 433.000 (Physician Services)

The MMS has reviewed the new policy for global payment of surgeries (global surgical package) proposed by the Division of Medical Assistance.  The proposal is described in hearing announcements as redefining payment for a surgical procedure to "include a standard package of preoperative, intraoperative, and postoperative services.  The services included within the global surgical package would not be payable separately, regardless of the setting in which those services were performed. In addition, the proposed regulations describe payment for multiple surgeries and endoscopies, add-on surgical procedures, bilateral procedures, surgical assistants, team surgery, and co-surgery (two surgeons)."

Regarding the specific changes, our reviewers think that several of the changes move Medicaid to be more aligned with Medicare.  In the interest of administrative simplification, such changes are highly desirable. However, the proposed regulation lacks specifics on implementation practices. If the changes are implemented inconsistently that may result in interpretations that are not consistent with Medicare or community standards in claims payments.  Examples of these changes are described below:

The use of global surgical periods has been a standard for some time.  The proposed change will align Medicaid with Medicare and other payers.  However, it should be noted that this will result in lower payments particularly for pediatric surgery where the Medicare based RVUs have been understudied. In the interest of assuring access to pediatric surgery the global rates for pediatric surgeries should be reviewed. Historically, Medicaid's payment for follow-up visits recognized the need and the desire to provide a greater level of follow-up to the care of Medicaid patients who did not have consistent social support.  Thus if services are not available for follow up care because of a lack of funding, there may be significant compliance issues leading to poor outcomes and increased readmissions.  The Division should carefully consider the impact of this proposal on likely readmissions.

Medicaid is proposing to follow several modifiers that are also consistent with the billing and payment practices of Medicare and other payers. However, the regulations do not specify the change in payment rate due to the modifier.  Most payers provide a standard rate and do not treat each modifier for individual consideration.  The department's approach will likely cause each case where a modifier should be appropriately applied to be rerouted for individual consideration.  Individual consideration of a large volume of claims will likely result in a delay of payment and an inconsistent application of the modifier.

The MMS strongly supports the use of modifiers, particularly modifier 25 and modifier 59 wherever applicable. However, inherent in the use of modifiers should be an increased simplicity and a known billing outcome.  Individual consideration should not be applied in cases where modifiers will become more routine as part of a global system.

The MMS appreciates the opportunity to present our views on this complex issue and look forward to working closely with the administration on the evolution of our payment system.

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