CRNA Payment Question Striking More Critical Access Hospitals

Several Texas Critical Access Hospitals (CAH) report being hit by audits recently where Trailblazer is adjusting downward the allowable on-call time for Certified Registered Nurse Anesthetists. Trailblazer is denying and/or attempting to recover payments from several Texas rural CAHs claiming the payments are for services not clearly deemed an “allowable cost” under Medicare. The hospitals contend the charges are have been deemed allowable in the past and no CMS rules have changed. The hospitals can appeal the issue, but that can take years and is costly. Plus, Trailblazer appears to be supported by CMS in its position.

The most recent incident involves Otto Kaiser Memorial Hospital in Kenedy. Hospital CEO Nathan Tudor and TORCH recently made a complaint to US Congressman Ruben Hinojosa who represents the Kenedy area. And, CMS has actually responded to Hinojosa’s office on the matter stating they do not consider CRNAs to be on the list of providers where stand by or on-call time is paid for. The CMS contention is that CRNAs are specifically defined separately in CMS rules from a clinical nurse specialist and therefore do not qualify as a “clinical nurse specialist” referred to in the on call payment coverage list.

The official reply submitted by CMS to Congressman Hinojosa’s office:

CMS policy is to only allow on call costs of clinical nurse specialists and NOT for CRNAs. The statute and regulations clearly limit the pass through payment to CAHs for specific emergency on call providers, including ER physicians, ER PAs, NPs and clinical nurse specialists (CNS). Throughout title XVIII, the statute clearly uses the terms CRNA and CNS separately.

A certified nurse specialist is defined in 1861(aa)(5) as:
(B) The term “clinical nurse specialist” means, for purposes of this title, an individual who (i) is a registered nurse and is licensed to practice nursing in the State in which the clinical nurse specialist services are performed; and (ii) holds a master’s degree in a defined clinical area of nursing from an accredited educational institution.

Separately, a certified registered nurse anesthetist is defined in 1861(bb)(2) as:
(2) The term “certified registered nurse anesthetist” means a certified registered nurse anesthetist licensed by the State who meets such education, training, and other requirements relating to anesthesia services and related care as the Secretary may prescribe. In prescribing such requirements the Secretary may use the same requirements as those established by a national organization for the certification of nurse anesthetists. Such term also includes, as prescribed by the Secretary, an anesthesiologist assistant.

Section 1842(b)(18) defines Practitioner

The term “practitioner” means any of the following
• Physician assistant;
• Nurse practitioner;
• Clinical nurse specialist;
• Certified registered nurse anesthetist;
• Certified nurse midwife;
• Clinical psychologist;
• Clinical social worker;
• Registered dietitian; or
• Nutrition Professional

Accordingly, had the statute wanted to include CRNAs in the list of practitioners for whom a CAH can be paid based on the reasonable costs of having them “on call,” the statute would have (and could have) specifically included CRNAs in the list.

The only recourse from the new CMS position is most likely a bill in Congress to override CMS. TORCH is in communications with Representative Hinojosa’s office about that possibility.

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