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there are crna independent practices in all 50 states well howdy youtube family it is bold crna coming to you with another week's topic this week we are going to talk about something that you guys asked me pretty frequently and it can be a little confusing admittedly when i was in training or not in training yet i didn't understand what this lingo meant medical direction medical supervision um q z billing these types of terms what do they actually mean so today we're going to talk into the details of exactly what that means all right so as of practicing crna i know what these terms mean but for today i'm going to use my handy dandy computer here and reference resources so that i can give you exact cited sources and and tell you specifically the lingo so i don't mislead you or confuse you at all you might still be a little confused because sometimes these things can be confusing but i'll try and break it down easy for you so the first thing you should really understand is these are terms that we're using when we're trying to get medicare and medicaid to pay us for our services this has nothing to do with legal practice abilities or our licensing abilities or anything like that is literally we want you to pay us for what we just did so please pay us so there's all these terms in in order for us to get paid properly and again this only counts for medicare and medicaid blue cross blue shield these other terms and stuff that doesn't that doesn't abide by any of these things these regulations and and lingo doesn't matter for these other outside insurance companies this is for medicare and medicaid so first let's start with the most restrictive kind of billing process that puts the most restriction on your practice abilities and that's called medical direction and i'm going to put it on the screen here behind me so you can kind of see the longer form of what i'm going to tell you but essentially medical direction means there's two parts to medicare there's part a and part b so medicare part b in all 50 states there's no regulation on crna's billing for that kind of thing you can do that independently no matter what it's medicare part a that has in some states the regulation where they want some type of supervision or direction in order for you to get paid by them so in those states you can either choose to do medical direction billing or medical supervision billing now medical direction billing like i said is the most restrictive and what this means is there can be one physician anesthesiologist to four crnas and this person can bill for 50 of each of these four rooms that are running while you each of the four crnas can build the other 50 individually so i'm getting 50 of the the billing revenue whatever for this case and the physician anesthesiologist who's medically directing me is also getting 50 of this profit of this case but they can have four rooms running at once so that means they're pretty much making 200 salary per hour because there's four rooms running 50 times 4 is 200 percent so while i'm only getting 50 percent of profit revenue from this they're getting 200 which is why you will find in the past this was a popular method to do billing although in the last probably 10 years i've seen a lot of practices switching from this type of billing to medical supervision which we'll talk about in a little bit and there's reasons why for that so i told you that it can be one physician anesthesiologist for four crnas and what's the deal here what's what's the problem what's the uh catch essentially with this type of billing model this billing model can be abused financially because of course one of you is getting 200 uh of the revenue for this these types of billing cases there's seven tethra laws that medicare and medicaid put on this billing model and they said you have to follow all of these seven tephra guidelines in order to legally bill for medical direction if you do not follow every single all seven of these guidelines for every single case you do and bill ever for medical direction it is fraud which is an extreme billing fee and a big issue if you're committing fraud by billing while you're not committing these seven tetfer guidelines so what are these seven tephra guidelines and tefr stands for t-e-f-r-a and i'll put it on the screen behind the physician anesthesiologist has to perform a pre-anaesthetic evaluation on the patient themselves they then have to prescribe the anesthetic plan they have to personally be involved in the most demanding aspects of the anesthesia case which includes induction emergence and if they're not personally doing any procedures in the case which means finals intubation central lines whatever they have to guarantee essentially put themselves attached to the procedure saying that it's being done appropriately or that this person who is doing it the crna who's doing this case is competent at central lines and if not they're tied to that the fifth thing they have to do is monitor the anesthesia at frequent intervals so they have to be frequently around and available and involved six is remain physically present for immediate diagnosis and intervention for emergencies during this case and seven is provide immediate post anesthetic care so they're responsible for the post anesthesia portion they're responsible for monitoring and managing that patient after surgery and in the recovery room and to be transferred out to the floor or discharged home and they have to document on each case that they did all of these things before the case is over and then you bill for it what happens though often with these types of seven tepher guidelines and as someone who did some perk dm work in a medical direction facility i can tell you from experience and i'll even show you in this article here it is very common for there to be fraud in some form for these cases whether they're clicking that they did all seven of these guidelines or not i can tell you that a lot of times their own the asa's own research has shown that a huge majority of the time a shocking amount of time these are not fully upheld all seven of these guidelines for every case that they are billed for which means fraud article that i'm going to link for you is actually showing you that you are also as that crna involved as one of those four people involved those cases even though it's not your responsibility to make that person do all these things because that's their job and they're getting paid 200 uh revenue for being there doing these things uh you are also in trouble as well for for being involved in a case where all seven of these things were not done so that's why medical direction is very problematic and also just as uh is not a good use of resources there is not any evidence to indicate that this is necessary or that crnas need to practice in this kind of model it's very micromanaging all in the name of someone making 200 profit i just don't work in medical direction or support that type of practice model at all so then you may ask so what's medical supervision mean a much looser term essentially this is a term that means collaboration this means that either you're working with a physician anesthesiologist or medicare says it can be any kind of operating provider so this can be a dentist this can be a surgeon it can mean a lot a podiatrist these types of people you can be working with and it can be considered supervision and really it just means that they're available or around if you needed them they don't really specify if what that means what immediately available means it it should mean that they could come to you if you needed help or backup or second set of hands or assistance or anything but it doesn't really specify like the amount of meters they have to be away from you or anything like that they could probably be on a different floor typically that's the way these types of practices operate they may be doing other things but essentially what it does mean is that this other person can't be somewhere else doing a tied up in a completely different case away from you unable to assist you if needed if you're billing for medical supervision so you might be wondering if you're billing medical supervision is everyone getting 50 of the payback or what's going on here no so there's no real limit to the amount of people that a physician can be or pedestrian whatever can be supervising so the way it works is they get three units of base time which is how we bill in anesthesia is use like 15 minute base unit at a time they believe they get three units and then the for each case and the crna still gets 50 uh they still bill for 50 of the revenue for the case so that's kind of how it gets divvied up and oftentimes these are in groups where you all work together so the same pot of money comes the same overhead source and then both people get paid a salary cut of that profit but that's essentially how it typically works when it's medical supervision the way that can be profitable is because you might have eight or ten crnas all running different cases and rooms you might have one physician anesthesiologist and they're getting three units per each of these cases that are going on and uh and i've worked in a practice like that before that was probably eight or ten of us and we it was pretty much all crna ran and the physician anesthesiologist did uh he did billing and he did administrative work in his office and we ran ob and we ran other things and if we ever needed help or assistance we would call him but essentially it was understood that people who came to practice there were independent providers that we're not going to need people to come help them often because he was oftentimes busy that's how that building worked and he really enjoyed it he didn't do much clinical anesthesia he did partake and help with some of the weekend call and he did help with a little bit of the call coverage and stuff for everybody so essentially that practice is how a lot of places that used to be medical direction have transitioned into medical supervision because it still gives the opportunity for a few crnas and and physician seven aesthesia guidelines that you follow that require extreme micromanagement and everyone stepping on everyone's each other's toes constantly and the very likely ability of committing fraud so we talked about these two medical direction medical supervision what about all these independent crnas you've heard about what about myself who practices independently what does that mean what's going on here there are 17 states that have opted out of medicare and medicaid supervision lingo the governor has said hey our state needs providers who can provide full practice anesthesia independently crnas are fully trained and able to do that and all evidence has shown that they're safe high quality anesthesia providers so why don't we actually just remove this supervision lingo from our state and that way they can provide independent anesthesia services california being one of them in you know 16 other states have done that which essentially means none of this lingo matters there is no supervision requirements there are no hoops you have to jump through or somebody signing signatures and all that kind of stuff for any of those 17 states but here's the interesting thing and i'm going to put a map up here to show you the states that are not not opted out in the states that have opted out the states that haven't opted out yet i even trained in one i trained in tennessee which is not an opt-out state yet it has a lot of crna only independent practices all throughout it and i was trained in quite a few of them so how does that work well crna's like i said our license and our ability to practice is completely independent what we're talking about with los lingo is being paid back for our services by medicare and medicaid which is important because you don't want to do free work you want to get paid for what you do so nobody's wanting to work for not without getting paid so it's important to address that and in these states that want these signatures a surgeon or like i said podiatrist dentists can easily in these practices that crnas work in they just have a standard set of pre-op orders that say i want anesthesia services rendered by the crna team and that order suffices for supervision over them for medicare and medicaid they don't really specify what the supervision really means they just want that type of request or signature there that covers and that is how everyone gets paid so even in the states that haven't opted out and do have physician supervision there are crna independent practices in all 50 states because this is a billing thing not a practice thing and then you may ask okay so what about you guys in the seven states that have opted out and you're not working in medical supervision or medical direction how are you billing we bill by what's called q z billing q z billing is a qualifier that shows medicare medicaid it is a non-physician anesthesia provider practicing independently and actually physicians uh have their own modifier that they use too when it's just them working solo without any crnas or anybody else and they're working by themselves in providing the anesthesia they have a modifier that shows that as well and we get paid by medicare medicaid crnas get reimbursed 80 percent of the total amount that we should get reimbursed for the services we get reimbursed 80 percent and physician anesthesiologists get reimbursed a hundred percent uh for the for the surgery or the case so me personally i practice under a q z modifier whenever we're building medicare and medicaid when i'm doing independent practice i you know go to a lot of different surgery centers and do a lot of independent work and so that's how it's built for me and i hope that kind of clears things up for you maybe it's clear as mud possibly but i wanted you to have an understanding i use these terms in lingo kind of interchangeably sometimes and people get really confused what the difference is in between medical direction medical supervision independent practice uh how can someone be practicing independently in a state that's not opted out yet and and do you have to live in an opt-out state to be an independent provider and what does being an independent provider mean and and you have to realize that our billing is a total separate issue from your license to practice and what you are trained and licensed to do and be able to do on your own that is totally separate from this so just keep those in mind when you're thinking about the two concepts i want to hear down from you below what you think about all these different billing models and the ways that crna's practice do you think this is confusing do you think that we should simplify it i want to stop real quick and do a shout out for all of you guys who are channel members if you're not a channel member go over here to the memberships i offer the 26 page study guide over there i offer you know one-on-one live chats with all of you guys every month i offer shout outs for the ketamine kings which we're about to do and some exclusive behind the scenes videos ketamine kings the true vips i want to shout you out with zara rasheed kendra lipar cali dolan sarah chung timothy cox kim chile 1989 uh jason fowler freddy chen madison montauk jenny escritor hunter wilson stephanie klein danielle managin manganelli hayden hinton christina rossi bryn canetta andrew rockinghaus evan wooten anonymous which i appreciate you've been around forever anonymous and you don't want any credit so love that about you matthew welters spider taco cynthia almonte and steven george a lot of you guys have been here quite a long time and i can see that here that a lot of you have been supporting me as kennedy kings for a long time i really appreciate you guys it means a lot to me all right guys if you haven't joined the crna circle go over there and do that if you're looking to get into crna score just interested in talking about it follow me on instagram follow me on tick tock it's both crna over there trying to put out some funny goofy content for you let me know if you like it and until next week that's bolt out [Music] you