For many physicians, that beast known as “revenue cycle management” is simply a necessary evil to get paid; the billing, coding, and collections that go along with it are arcane rigamarole they’d rather not deal with.
But from the earliest days of his training, Ezequiel “Zeke” Silva III, MD, embraced all of it.
More than 25 years later, the San Antonio radiologist’s expertise in those areas has paid off and helped elevate him into one of the American Medical Association’s (AMA’s) most important voices on physician payment.
In March, Dr. Silva began a two-year term as chair of the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The volunteer panel of more than 30 physicians advises Medicare on its physician fee schedule, focusing in large part on how shifts in science and technology should affect payments.
With technology in medicine advancing perhaps faster than ever – think COVID-19 and the subsequent pedal-to-the-metal adoption of telemedicine – Dr. Silva’s new role is coming at a pivotal time. And telemedicine and telehealth, he notes, aren’t the only technologies remaking patient care.
“Think about other digital technologies like remote patient monitoring,” he told Texas Medicine. “Think about augmented intelligence (AI). Think about digital therapeutics. These are all services that five, 10 years ago were sort of in their infancy. Now, we’re seeing those services coming to the forefront, and physicians are saying to us at the AMA, ‘We see these services coming into patient care. We recognize the value of these services, we are embracing these services, we require the resources to provide these services.’ And patients are saying the same thing.”
The stuff you “can’t get away from”
The RUC is charged with evaluating potential new current procedural terminology (CPT) codes for the Centers for Medicare & Medicaid Services and making payment-related recommendations surrounding those codes. For example, when faced with the COVID-19 public health emergency, the RUC helped CMS arrive at codes for personal protective equipment (PPE) as well as the COVID-19 vaccine.
For Dr. Silva, the path to leadership in that area began during his residency rotations at Baylor College of Medicine in Houston, when one of the attending physicians gave coding quizzes on interventional radiology procedures.
“We had to indicate exactly which code represented what we had just done,” he said. “If I took a catheter and I put it into a patient’s liver … or their brain, or whatever, he would require that we would indicate what code we’d use on a billing charge master.
“For some reason – I still to this day don’t exactly know what it was – I thought it was interesting that someone had actually taken the effort to look at all the procedures that were done by physicians and assign a five-digit numeric code to describe them. I started reading everything I could about how the AMA managed such a complex endeavor.”
So when Dr. Silva began his career in San Antonio at South Texas Radiology Group in 2002, revenue cycle management became one of his focuses. Since then, he’s served in a number of capacities surrounding it, including chairman of the economics committee of the Society for Interventional Radiology and chair of its coding and education sub-committee. More recently, he has served as chair of the American College of Radiology Commission on Economics, and he’s a current member of the Texas Medical Association’s Council on Socioeconomics.
Dr. Silva acknowledges, though, that not every physician has climbed on board that same wonk-ish journey – one that introduces not only billing and coding arcana, but also the “alphabet soup” of nonstop initialisms and acronyms, like the QPP (Quality Payment Program) and MACRA (Medicare Access & CHIP Reauthorization Act).
“You have to be purposeful in your educational efforts. I think the TMA does a great job of this, and I think the AMA does a particularly good job of that as well,” he said. “When you’re discussing these types of topics with practicing physicians, you really need to maintain an element of practicality to it. Because payment, revenue cycle management, billing, compliance – all of these aspects – we can’t get away from them. They’re inherent to what we do.”
The AMA CPT Editorial Panel creates the codes, and the RUC works with the panel to determine their value.
To arrive at its recommendations, the committee randomly surveys members of the specialties that perform the procedures/services in question. They look at the time involved for physicians; the mental and physical stress the service places on physicians; and the expense to the practice, including staff and equipment expenses.
The RUC doesn’t determine payment in dollars; rather it determines where the service falls on CMS’ resource-based relative value scale, which the federal agency uses to determine payment.
It’s important for physicians to be in the lead on that process, Dr. Silva says, because personal experience and clinical expertise are vital to both identify new patient-care services and understand existing ones.
“You’re comparing new services to existing services; it’s a relativity perspective,” he said. “So you have to understand that entire spectrum of clinical practice. To see new innovations coming into medicine, it’s the practicing physicians that are the ones that are seeing the results of those technologies. They’re seeing the patient benefit.”
The digital challenge
Since 2018, Dr. Silva has been chair of AMA’s Digital Medicine Payment Advisory Group, which he helped form in 2016. Dr. Silva’s RUC service began in 2016 as well.
It was during that year, he says, that the digital payment advisory group really dove into such emerging technologies as telemedicine and AI, and began advancing legislative and regulatory policy surrounding those technologies. For example, the advisory group was able to win expanded coverage for tele-radiology – one of Dr. Silva’s longtime points of focus – by advocating for the lessening of geographic site restrictions.
Fellow Texas physician Russ Kridel, MD, chair of the AMA Board of Trustees, lauded Dr. Silva’s appointment to RUC chair in an AMA release in February.
“The rise of the digital-native physician will have a profound impact on health care and patient outcomes, and the RUC will be increasingly called upon to assess the impact of digital health technologies on patient care,” Dr. Kridel said. “Dr. Silva’s respected insights into emerging digital technologies and his leadership qualities will help guide the RUC’s vital work as a source of physician input on policies that govern Medicare.”
Dr. Silva says the technological transitions happening now in medicine were predictable, but “we could never have predicted they would occur with this degree of urgency and this degree of timeliness which the COVID-19 public health emergency required.”
It’s a challenge for the coding and payment side to keep up with the speed of change, he says. And when new services and potential new codes hit his desk for consideration, the RUC takes its time, which has an upside and a downside.
On one hand, the RUC carefully, purposefully, and objectively evaluates new CPT codes. On the other, it may take longer for new innovations to become available to patients and physicians. However, Dr. Silva notes, when speed is of the essence, the AMA and RUC can act quickly, as in the case of evaluating new codes for COVID-19 vaccines and PPE.
Developing the PPE codes was “in response to direct feedback we were hearing from physicians. We were hearing from physician practices that for understandable reasons, because of the infectious nature of COVID-19, they were having to take additional measures to protect their staff and their patients. Those additional measures … resulted in increased, incurred expenses for those physician practices.”
Going forward, he believes the pandemic provides medicine with a wealth of data and a new obligation.
“Now that we’ve seen the largest pilot study in the history of mankind – which is this pandemic – we have the responsibility in medicine to look at what our experience was during that time,” he said. “We have all this claims data, all these services provided, all this data on physician experience, patient experience, outcomes, metrics to postulate the effects of decreased screening, examinations, and elective surgeries.
“We have these massive amounts of information out there, and now it’s going to become incumbent on our health policy researchers, our physicians, our advocacy organizations, the TMA and the AMA, to look at all that data and decide what worked and what didn’t.”
His goals as RUC chair: build on the committee’s 30 years of experience in payment policy while evolving as technology and innovation dictate. He says he’ll always advocate for physicians to be involved in the technical and procedural sides of payment.
“As long as I’m doing this,” he said, “I’ll continue to assert that the more we as physicians can place ourselves at the center of those discussions, the better it is for patient care, and the better it is for our profession.”
Tex Med. 2021;117(5):28-30
May 2021 Texas Medicine Contents
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