PAMED, Specialists, Applaud Highmark for Reconsidering Coverage Criteria for Monitored Anesthesia Care

The Pennsylvania Medical Society (PAMED), working closely with several specialty groups, responded to Highmark’s recent announcement that they were initiating medical necessity changes to their Monitored Anesthesia Care (MAC) policy involving colonoscopies, gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures.

As a result of these talks, Highmark on May 30 decided to delay the policy and continue discussions with a work group comprised of representatives of PAMED, the Pennsylvania Society of Gastroenterology (PSG), the Pennsylvania Society of Anesthesiologists (PSA), and the Pennsylvania Ambulatory Surgery Association (PASA). The change in coverage was scheduled to take effect July 1.

“After receiving feedback, including concerns, from some physicians, we have decided to delay implementation of the policy as we further study all implications of this change,” said Highmark in a May 30 statement. “Physicians have told us they would need more time to make adjustments within their practices to accommodate the change. To understand fully what this will mean for them, we will seek their input and meet with representatives of the Pennsylvania Medical Society.”

In a recent press release, PAMED said, “We applaud Highmark’s decision to delay implementation of their Monitored Anesthesia Care policy that was to go into effect June 30, 2014.” The physicians “felt that this policy was not in the patient’s best interest clinically and financially and therefore expressed their concerns with Highmark. Highmark has agreed to work with the physician community over the summer to further discuss this policy.”

Richard O’Flynn, president of the Pennsylvania Society of Anesthesiologists and chairman of the Department of Anesthesia at Mercy Hospital of Philadelphia, told the Pittsburgh Tribune Review that Highmark’s initial decision to stop MAC coverage for these procedures would be “very shortsighted on the part of an insurer. It's potentially dangerous to our patients.”

The physician groups are concerned that discontinuing coverage of MAC may discourage patients from seeking colonoscopies when they’re needed.

According to a Highmark spokesperson, the company’s decision to alter its coverage of propofol “is not cost-related” and instead was prompted by the drug's potential side effects. The drug can affect breathing and blood pressure.

The change would apply to healthy patients who don't have other significant medical conditions. Highmark would continue to cover propofol for patients with underlying medical conditions who undergo colonoscopies for example, and the decision on which anesthetic to use would be made in conjunction with a patient's doctor, she said.

In light of Highmark’s recent decision to delay implementation of their MAC policy, PAMED also wants to make sure physicians are aware that Novitas Solutions, the Medicare carrier for Pennsylvania, has drafted a similar MAC policy. PAMED encourages physicians to voice their feedback, including concerns about the implications of this policy during the comment period, which ends July 10. Read more, including how to comment.

Last Updated: 6/5/2014

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Comments: 2

Over the years, we have stressed the benefit of colonoscopy and other methods of colon cancer screening to prevent mortality and morbidity. Insurers have found this to be so important that they measured this and adjusted what they paid us based upon our success. No one gets colonoscopy without anesthesia-having done flexible sigmoidoscopies without anesthesia in the past, no one wants a colonoscopy without anesthesia. I have had 3 EGD's without anesthesia and one with--I will not even consider having it done again without. I suggest 20 Highmark leaders have a colonoscopy without anesthesia prior to any rule being made. Highmark's comment "According to a Highmark spokesperson, the company’s decision to alter its coverage of propofol “is not cost-related” and instead was prompted by the drug's potential side effects. The drug can affect breathing and blood pressure." is true, but that is why the anesthesiologist or nurse anesthetist is present. Were there no anesthesia, the patients would be likely to jump off the table and have potential side effects of torn rectums and broken hips. I believe MAC anesthesia is safer and more patient friendly, not to mention, it will improve patient satisfaction scores!

A concerned Family Physician at 6/2/2014 2:23:30 PM

Highmark's reasoning is flawed. If their decision is based on the potential side effects of propofol and it's effect on breathing and blood pressure why will they continue to pay for its use only in patient's with multiple co-morbidities and not healthy patients? This is clearly a cost-related decision.

anonymous at 6/2/2014 1:41:25 PM