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Compliance Implications of E/M Changes

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Rob Stone, Alston & Bird, and Valerie Rock, PYA, talk about E/M code changes expected in early 2021. The speakers summarize the expected changes, examine their impact on documentation requirements, and talk about how the changes will likely impact physician compensation and other compliance issues. Sponsored by PYA.

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Speaker 1:

Support for A H L A comes from p y a For nearly 40 years, p y a has helped clients find value in the complex challenges related to mergers and acquisitions, clinical integrations, regulatory compliance, business valuations, and fair market value assessments and tax and assurance. P y A is recognized by Modern Healthcare as one of the nation's top 20 healthcare consulting firms, and by inside public accounting as a top 100 accounting firm. Learn more@pyapc.com.

Speaker 2:

Hello and welcome to this, uh, addition of the American Health Law Podcast. My name is Rob Stone. I am a partner in healthcare group of Alston and Bird out of Atlanta, uh, specializing in healthcare regulatory and compliance. And, uh, reimbursement matters topic we have for today, uh, is the pending, uh, evaluation and management code changes that are looks like coming January of 2021 and impacting, uh, really sort of a surprising range of, of areas, I think a number of which maybe were not even intended by the rule makers, but, uh, involving both documentation and RVU calculations and, and reimbursement and compensation. And we're gonna, we're gonna spend some time talking about all those matters. Uh, the, the three categories that we're planning on going through before I, uh, I let my co-presenter introduce herself are first just an overview of the changes from a reimbursement perspective at a high level. What are we, what are we anticipating, uh, how do we think mechanically things are gonna work, uh, and impact various aspects of, of reimbursement. Second, looking at impact on documentation requirements with respect to the impacted codes, which is one of those areas that I think will have some unintended consequences around, uh, things like due diligence and audits. And then finally, uh, as a third area from a compliance and compensation standpoint, how will these changes likely impact, uh, primarily physician compensation, which has been built up a lot, uh, on the under an R V U model, uh, over recent years. And then related matters around compliance and fair market value and, and confirming that, uh, compensation arrangements remain compliant. With that, let me hand it over to, uh, to Valerie Rock. Uh, Valerie, if you wanna introduce yourself and then maybe just kick it off by talking a little bit about this first category of summarizing what the reimbursement changes are looking like.

Speaker 3:

Yep. Thank you, Rob. So, again, my name, name is Valerie Rock. I'm a principal at P y a and we're a national consulting firm, um, an accounting firm. And our practice in the consulting space is really focused on healthcare. So I oversee our revenue integrity services, which includes hundreds of coding and billing compliance reviews of thousands of records per year. Um, but I've been fo closely following these e and m and other coding and reimbursement changes since I was credentialed, um, in the coding arena, um, around 2005. Um, so, and I've been with the firm for 17 years, actually as of today. So, um, I'm happy to be here. Congratulations. Yeah, thank you, Rob. Um, so that, happy to be here to talk through this because this is a very, um, big change, a big, um, change for the physician community in regards to these e and m changes. And, um, because of the reimbursement impact. In addition to that, uh, we're definitely going to see, um, a lot of concern, um, and we're already starting to see that, um, because of physician comp impact. So, as an overview, kind of have to start, uh, a little bit basic to make sure we're all on the same page. So, an E n M code is an evaluation and management code, and that is what, um, you would consider a visit. So if you go to a, an office of practice and you go see a physician and you're there to talk through your history and they do an exam and you are given a prescription and that kind of thing, that visit is an E N M service, which is, is, um, identified on a claim by a code. And those codes for the office visits are 9 9 2 0 1 through 9 9 2 15. And, um, when we're talking about these changes upcoming in 2021, and office based code is the only type of code that we're talking about, there are a and m codes that are in the hospital setting. There are e and m codes in the skilled nursing facility and, um, emergency department setting, but we're only talking about office-based codes when we're talking about these changes in 2021. We do anticipate changes upcoming for those other, uh, types of categories of service, but, um, as of right now, we only have these 10 codes, which are actually being reduced to nine codes. Um, in 2021. E and m codes have three components. So they have history exam and medical decision making as, um, their key elements. And those were kind of put forth in 1995 and 1997 guidelines that, um, were not created by cms, but were adopted by CMS back in those given years. So, um, in addition to that, if we shift then and talk about work RVs, um, work VUS are one of three VUS that are, that create parts of the calculation for the Medicare reimbursement. Um, the other component, and there's another one, but the other key component to that is a conversion factor. So the work RVU is in indicative of the physician work effort. And, um, then you have the practice expense and the malpractice, um, work rvu and all of those work vus are, are added together multiplied by a conversion factor. So I wanna make sure that we're all on the same page with that, because that is really kind of where the underlying, um, elements are for all of these upcoming changes. So

Speaker 2:

When was and Valerie, that that process you're talking about of adding work VUS up and then multiplying by a conversion factor mm-hmm.<affirmative>, what that produces is the amount of reimbursement, right? Yes, sir. Particularly with respect to, to Medicare. Um, and then other payers may adopt, uh, the same method, but Right. That, that's how you figure out how much you're gonna get paid by Medicare on the code is how many, how many VUS multiplied times a conversion

Speaker 3:

Factor, right? And that's what's, um, you know, put out and put forth in the Medicare physician fee schedule each year, any changes to those vus and the conversion factor, which is what this discussion really, um, kind of lies, you know, kind of comes back to. Um, so when we then look back and see where did these E N M uh, services, how did they change and how did this come about? We have to start back in 2018. So in 2018, there was a model put forth in the Medicare physician fee scheduled by C M s that, um, contemplated removing the history and exam component components and only utilizing the medical decision making or time as the way to select the service. So this was an interesting potential change in 2018. In 2019, um, there was a contemplation of the actual value of, um, those services, but they did not go back and survey and actually revalue those. They said, well, let's just flatten the, um, reimbursement amongst the level two through level four service. The industry pushed back very hard on that, um, and disagreed with that fully and said, no, that's not the way to do it. And the ama um, and the C P T committee under the ama, um, designed and came together along with C M S and designed new guidelines around the e these E N M codes and re um, redefined the E N M codes within this set. So as of the 2020 final rule, we had new guidelines for e and m codes, new work, RVU values, um, and all of, so all of that was finalized, um, in 2020. It was in 2019 that they actually did surveys of 70, uh, uh, specialty, uh, specialties and 1700, uh, physicians that put forth their information through survey data on what those work VUS would constitute the time, the work effort, and all of that. That would then, um, be what they would rely on for potential changes to the work RVs. So they finalized those in 2020 to either be stable or an increase for every single one of those codes. Um, but they eliminated the 9 92 0 1, um, in the process of that. So, um, the issue now is that because c M s is required to neither increase nor decrease the fee schedule by 20 million, they had to put a budget neutrality adjustment on the, uh, com on the conversion factor to decrease those, the total, um, adjustment there. And they, they utilize a negative 10.6% adjustment that is in the proposed rule, Medicare physician fees schedule proposed rule right now. Um, and now we're awaiting, um, now we're past the comment period, and now we're waiting to see if they're going to actually apply this 10.6% negative adjustment or not. And, um, so that's, a lot of the comments actually said that they wanted them to remove that, and some believe that because we're under pr, uh, public health emergency, that C M S would have the authority without legislative action to actually remove that 10.6% adjustment. But Rob, I know that you've seen some additional information about that come through. Maybe you wanna talk through what, what we might see, um, when the final comes out. Yeah,

Speaker 2:

Absolutely. And, and maybe before we do that, if I can just, um, take one step back and, and interpret the, the coding, uh, angle for lawyers just to mm-hmm.<affirmative> to try and make sure we're all on the same page and talk a little bit about kinda the underlying rationale for what we're seeing. The, this summary position is there was a move to sort of revalue in a positive way, these office visits that was part driven by, I think, primary a view that primary care was perhaps undervalued historically. And so the goal was, you know, the R in RVU is relative value units was to take all the codes and increase the work RV use for the office visits to sort of say, Hey, we're, we're undervaluing primary care in these office-based practices, so that relative to other codes, they're gonna have a higher value mm-hmm.<affirmative>. And that in effect would a, allow them to be paid more. Uh, all else being equal, the problem is cause of other rules around budget neutrality, all else is not necessarily equal. And so CMS is coming in and saying, well, yeah, that's great, but if you're increasing the office visits for those guys, that's increasing our total spend. Now we may have to knock everybody back down 10%. So you've got kind of, you know, six dimensional chest and multiple levers and dials moving to try and figure out the net net of all this is, is really complicated. Um, and, and, but I think you can understand from a policy standpoint and the trend lines as far as what the goals were. So that's just kind of the level setting of, of where we are. The really interesting potential change that, that Valerie was just referencing is that we're hearing, um, and in fact have seen a bill introduced to hold harmless, uh, physicians under these changes through potentially bonus payments. So, um, if you, if you have a certain amount of this going through the normal physician fee schedule process that a jolt, uh, uh, results in some winners and losers, so to speak, relative to last year, there are discussions going on potential legislation after this, assuming the final rule with the 10% decrease gets finalized, there could be a legislative fix that would provide for bonus payments to kind of, I guess, get back to that policy position, which is we're not, the, the changing in the relative value units for office visits wasn't intended to decrease payments for proceduralists and surgical specialties. It was intended to increase payments for primary care areas. And the, the notion would be this legislative fix could actually rebalance things in that direction. Don't know whether that's gonna pass. Obviously legislation is a trickier matter than, uh, potentially than regulatory changes. Uh, but, but that, that bill was introduced recently and, uh, you know, we've seen some commentary and industry discussion about that. So that could, that could be another factor that impacts this. Um, quickly, Valerie, if you could just talk about two other two other concepts before we move from reimbursement to really digging into documentation. One is the, the impact, if any, of losing the level one code. So it seems sort of odd, they've always had one to five mm-hmm.<affirmative> and, you know, level five was, uh, sort of the maximum level of complexity and involvement for an office visit. Level one was the least. They're, they're getting rid of level one. Just sort of re-shifting everything from two to five. What, what's the impact of that, do you think, uh, if any, is there just a reflection sort of like, you know, if we got rid of the penny<laugh>, it's kind of a superfluous thing that doesn't really have any meaning anymore. I'm just curious what your take is on that.

Speaker 3:

Yeah, so the reason why it occurred is because the medical decision making level between level one and level two was no different. So we had four levels of medical decision making, straightforward, low, moderate, and high. So because both of those were straightforward, there was no reason to have an additional code. So the reason why the level one established patient remains is because that's always been the nurse visit. So we basically have physician level services or two through five, and the nurse visit is that level one, but we didn't need a new patient level one. And, and effectively the physicians weren't utilizing that level one anyway, so, um, got it. I don't anticipate it having or creating a big shift anywhere because they just effectively were not being used.

Speaker 2:

Okay. And then the last question in this reimbursement section, um, the, the, there's a, a new code, the GPC one x mm-hmm.<AFFIRMATIVE> code. Yeah. That's sort of an add-on. Um, and I know you and I have talked about some potential risks related to use or overuse of that code from a compliance standpoint, but maybe you could quickly summarize that and talk about, um, pros and cons of, of using that code. Mm-hmm.

Speaker 3:

<affirmative>. Right. Uh, the biggest issue is that it has not been clearly defined. Um, the proposed rule states that, uh, they're looking for comment back to define out how they should really define it. They have a definition which is effectively that, um, that they're trying to pay for complex services. So, uh, chronic conditions, at least one chronic condition, um, that is being managed by a physician or, uh, a patient where they're like the center point, like a primary care physician that's managing all the other care of that patient, trying to pay, pay for that type of service that is outside of the E N M service on a particular day. Um, what the issue is, is if there's differences of opinion on how that is applied or there's, if there remains confusion outside of the final rule on how that's applied, there could be some potential compliance risk, um, for Medicare coming back and saying, well, we never intended to pay you for that, for that type of scenario. Um, and it appears also that c m s, um, in its application of that code within the fee schedule that impacted that, um, 10.6% increases that they applied it a hundred percent to some types of specialties. So it's not real clear how exactly they did that. So I think there's a lot up in the air about it. Um, so it'll be important to really understand from the final rule where they land.

Speaker 2:

So yeah, the, the way I think about that, and this may not prove to be accurate, but if you have a primary care practice that that sort of zeroes in on this focal point of care concept and says, well, I'm the focal point of care for every patient who walks in the door mm-hmm.<affirmative>, therefore I should use, use this, this code. Um, even if some significant number of those patients don't have any other specialists, they see, right, right. It wouldn't make sense, even though technically you are the quote, the focal point, you're sort of the hub in the hub and spoke model. There are no spokes mm-hmm.<affirmative>, then there's really no need for you. It's not appropriate for you to bill. So you just have to watch that you don't default to using that to, to generate more revenue, even if there's some, you know, some kind of argument that, that, uh, it applies. Okay. Right. Um, well that's great. Let's move on to our second topic or sort of category for discussion around these documentation changes. You, you referenced, uh, a move away from the history and exam component more towards medical decision making. Maybe you could take a minute and just talk about, kinda a little bit more detail of what, what did that look like before? Like what's the current state for history and exam and medical decision making, and then how do you imagine the, the documentation and coding exercise of the future in 2021 will be impacted by those changes?

Speaker 3:

Mm-hmm.<affirmative>. So to think about that, we have to think about how EHRs were created, um, because most physicians are documenting within an EHR today. And, and when those EHRs were developed, they were developed based on the 97 guidelines. So the 1997 e and m guidelines were the basis because they have these specialty specific, um, exams that were easy to just create a template out of, basically. So we had the, um, history elements that include, included all the review of systems, which, you know, there's 14 review of systems, and the highest element number that you really need for any code is 10. And then you have your past family and, uh, social history, um, and then your eight organ systems that you need for the highest level of e N M code. So you often saw in this is what C M S talks about in, in the guidelines or in, in their, um, proposed and final rules as note bloat. And, um, so what they're trying to reduce is this excessive documentation, um, within the record because everything is built on the same platform. And a lot of physicians, um, as they're, you know, getting an E H R and they're trying to develop templates, we'll remove certain elements and say, well, this is my set of normals for this type of condition, or this, you know, a new patient or established patient. And so they'll develop those templates based on that. And then so they have their set of normals and, um, what all would all would be included normally. And then they would remove that, you know, remove anything that was, um, not necessary for that specific visit, or they would modify it. Um, but because of the speed that physicians are going these days, um, oftentimes that stuff is just blasted out and then they will manipulate what is different. Um, but they may not get back to taking out things that were unnecessary for that visit. And that causes some of the, the problem in the notes, um, having these new guidelines and moving away from history and exam doesn't necessarily mean it's going to be an easy switch in an EHR to remove all of those elements. It's not going to be more efficient to document everything freeform. And, and most of the, um, EHRs are not really, you know, they don't have a very robust section for documenting history and exam in preform, um, text spaces. So, uh, it is likely that, um, we'll see documentation effectively say the same, um, going forward. Now, if, if as people get more, you know, text savvy, um, as the EHRs become more savvy, as we get a little bit more interactive with our systems, and maybe even to the point where we're, you know, I, I kind of envision in the future that the physicians are gonna just talk to the walls and the walls are gonna pick up, um, what the history and exam is and all of that and document it themselves. So, you know, I think there's a future to reducing that history and exam, but right now it's going to be difficult to take it out. Um, but go

Speaker 2:

Ahead. And that's not prohibited, right? I mean, you, you can still include it, but the, the point of the documentation changes is that it's, it's not, uh, required to sort of repeat an every new note. If you can look at the, the record as a whole and, and get what you need to out of it from a medical decision making standpoint. Is that fair?

Speaker 3:

That is. And, and the fact that it's just not part of the, um, how you choose or select the level of service. So history and exam are removed from that thought process.

Speaker 2:

So I guess, you know, one question, medical decision making sounds very, um, subjective. Mm-hmm.<affirmative>, it sounds sort of qualitative and judgment based. Um, if, first of all, um, you know, correct me if I'm wrong about that, but, but if there's truth to that, does that impact, uh, auditing in terms of due diligence? For example, are we gonna end up with a lot more arguing between a, a target practice that's undergoing diligence in a coding audit as a part of diligence where they're gonna start really sorting, you know, fighting back and, and having a ground to fight back more cause the coding requirements become more subjective under this model?

Speaker 3:

Well, the way the medical decision making has been revised by the AMA ccpt, um, committee, um, is now a bit more quantitative. And it, it's always had some quantitative elements to it, but it, it really gets more quantitative now. So now we have the number of diagnoses, the data elements, and, and there's like accounting process for those data elements. And then the risk to the patient, um, is not as quantitative, a little bit more subjective. Um, but because we only need two of three of those elements in order to select a level, then we do have the ability, you know, for example, if, um, you have two or more stable chronic illnesses and you prescribe a, a drug, then you have a level four visit period. So it's it, because that seems pretty straightforward. I don't think it's going to be always the case that there's going to be arguments, um, in regards to the clinical aspects. But when you do have a scenario where, you know, in the level five visit you could have, um, one acute or chronic illness or injury that poses a threat to life or bodi bodily function, threat to life or bodily function can sometimes, um, be a question of subjectivity. And, um, because the guidelines also add some elements, uh, in language, um, that describe it, that it needs to be in the near term, not, not that it's just long term a threat to life, but that it's a near term threat to life. That also is kind of a modifying factor to, um, the way you look at this. And some people might miss that, um, in the guidelines because the, the, the grid itself does not clarify that, and the old guidelines, they not clarify that.

Speaker 2:

No. Um, closer to emergent, maybe not quite an emergent case, but something that's not like a chronic condition or like smoking might be a long term risk, but it's gotta be something that's more near term. And, and the, the other, I think the other important thing for non coders to understand is the distinction between documentation of medical decision making as you just described, which has some subjectivity, but it is still something that coding, uh, auditors can review. There are quantitative elements, there are things you can sort of look for that are, that are yes or no elements mm-hmm. As opposed to medical necessity that may require a clinician, this, these changes are not going to require, um, inherently physician or nurse reviewers to be used, uh, routinely for diligence. Correct.

Speaker 3:

Correct. That would not be necessary, um, routinely. Yeah. Right.

Speaker 2:

Got it. Um, well great.

Speaker 3:

Yeah, please. One thought about the due diligence though is that as we are, um, moving closer and closer to 2021 or as we're in 2021, but still looking at 2020 as a factor, um, I think we'll have to split the e and m reviews and show a error rate for 2021 versus 2020 because blended, it won't tell you real really where the story is kind of future look retrospective look. So, um, I think, I think it would be wise to split those reviews.

Speaker 2:

Yeah. There's gonna be a transition period where you've got kind of a straddle if you are doing a deal at the end of 2021 mm-hmm.<affirmative>, you may need to, to really get a picture of both how they're doing it in the new regime and the old regime. You know, that's a good point. Right. Okay. Well, let's, let's move on to our last topic, our last category around kind of the impact on physician compensation and compliance in that area as a result of, um, these changes primarily related to the work RVU adjustments mm-hmm.<affirmative>, um, you know, so many providers, physician groups, health systems have moved towards using some form of work R V U model, uh, in terms of physician compensation frequently with some kind of a base payment that then has a phy, uh, RVU threshold amount. And once that threshold is, is surpassed, then there's a bonus per work RVU earned above the threshold that goes to the physician. And suddenly going back to the top of the discussion, um, you've got kind of multiple of these levers being impacted. You've got, um, the number of VUS that are generated by certain codes changing. You've got the amount of revenue cause of the conversion factor adjustments that is generated by all of the, um, the codes mm-hmm.<affirmative> potentially being having some negative impact. Right. And then depending on this, this bill that we were talking about, there could be an add-on payment mm-hmm.<affirmative> that occurs outside of the physician fee schedule to try and bring things back, you know, in line with the policy, which is really just to pay more for office visits. So you know, what's evaluator to do, uh, when you're, when you're facing kind of these multiple moving targets that you can't just have a one size fits all approach, I wouldn't think, no. In trying to sort out, um, physician compensation.

Speaker 3:

Right. So what, you know, there's a couple, like you mentioned, there's a couple factors, um, there that are involved. And a lot of it has to do with the individual physicians utilization. You know, are they utilizing more e and M codes? Are they, are they, you know, hospital, hospital-based physicians? Are they, um, you know, uh, surgical providers? And then what is their contracted, uh, conversion factor on their work rvu? So, you know, in a, in that compensation model, you have a conversion factor that is based on what the valu, addor determined would, would be reasonable that would get them to fair market value. So, um, if all of that is kept the same, then you could end up with a physician making more money, um, and, you know, without that being adjusted for, you know, the market or any other factor there. And the question is, um, the valuators are trying to contemplate, is this a market adjustment and therefore, you know, just a correction into the market, um, or is this something else? And, and I would say that based on the fact that there was a survey done, and this is the valuation of the worker of use was to consider the actual work is being done now versus, um, you know, years ago when they were valued. And so we're kind of correcting what that value is versus, um, you know, kind of arbitrarily giving it a number. Um, and if that's the case, then there's reason to believe that, you know, someone that does a lot of e and m services in the office would be paid more for those services. But how do you then deal with the fact that a, you know, a surgeon is going to make less next year if you have that aju negative adjustment? Um, and, you know, are they still at fair market value? So we've seen a couple of different ways that, um, providers, hospitals, um, employers are handling this and some are saying that they're not going to do anything, that they're not going to change the conversion factors, they're not going to freeze any of the fee schedules and things like that. Um, they're just gonna let it go wherever it goes. And then others are saying they're going to freeze the conversion factor or decrease it if, if an individual study warrants it. And then some are saying that they're going to, um, freeze the work RV the VU values to the 2020 fee schedule so that they, they kind of keep everything somewhat flat. Um, and then some are going to increase the work RVU threshold so that, that it doesn't allow them to, um, get that bonus too soon. Um, so we're seeing a, a wide variety, which technically means that when we start seeing the surveys come out, uh, for the, what's occurring in 2021, um, when we get that in 2022, we're gonna have a mixed bag on what everybody did. Uh, with that. And, and also these surveys are, are basically, you know, difficult to follow at this point cuz 1 20 20, we have covid to play with<laugh>, um, 2021, we're gonna have this Medicare physician fee schedule change. And so we won't really kind of level out till 20 20, 20 22 or 2023. So there's going to be a lot of, um, you know, decisions that are made on a, I guess a comfort level on where you can get to, to determine fair market value. But Rob, I think those bonus payments will be another factor that'll be com con, you know, difficult to anticipate and contemplate if you don't know what that amount is going to be.

Speaker 2:

Yeah. I mean, look, you've got what is a market disruption mm-hmm.<affirmative>, right? If, if you're thinking about fair market value, that requires a functioning market for some period of time in order to understand what the market is doing. Mm-hmm.<affirmative>, because decisions by all the people in the market and, you know, employers' decisions around their comp models, doctors' decisions around where they wanna be employed based on compensation, uh, profitability that's driven by these comp models. You know, all these factors sort of move the market in different directions. And there's just too much variability, I think, and too much, uh, that we can't completely anticipate right now. Covid combined with, I mean, we're still waiting to hear final rule on the adjustment. We're still waiting to know whether there didn't be a legislative fix. To your point, if we don't shake out until 2022, it takes a couple more years, at least a year for the survey data for that period to then be, uh, you know, gathered and made available. Mm-hmm.<affirmative>. So there we're, we're going to be entering a period where there is a greater degree of uncertainty. Um, and I think a greater degree of variability among Valuators, which, you know, I think as a regulatory lawyer dealing with Starkman kickback and physician physician comp on a regular basis, I think having, uh, a, a, a qualified, uh, healthcare consultant evaluator who can look at this stuff, even if it's not quote unquote perfect or right, because there's, there's no one right or perfect answer. I do think even more than usual, there's comfort to be had in having an analysis done. Um, so that both from a financial operational standpoint and a compliance standpoint, you can, you can have some comfort level that if you were to get questioned, you're not just relying on sort of your own instincts or self-interest, you're able to point to a third party coming in from a purely regulatory standpoint. Uh, it, it, this, this situation creates and sort of highlights tension in the fraud and abuse rules among a couple of cornerstone or keystone concepts, right? The notion of fair market value, which we talked about, it requires a market and it requires information about the market before you can really have confidence level. But also, um, if you want to take these changes as an opportunity to reassess perhaps a multi-year arrangement or a year by year in, um, in a, a scenario that requires that you have set in advance your compensation, um, the, the tension between keeping your compensation with the fair market value and having your compensation be set in advance is always an issue. Because if the market changes, then you may be constrained in changing your compensation if you want to keep it set in advance. And generally speaking, my view is, and I think a number of others in the industry share this approach, if you confirm your fair market value and you enter into an arrangement, then you keep it for some appropriate period of time, even if the market fluctuates in the middle, that you, you should still be viewed as being in compliance. Cause the, the, the rules do favor, um, that you, you have compensation set in advance so that you can't monkey with the compensation as either a reward or penalty for referrals. Mm-hmm.<affirmative>. And I think if you're acting in a, in a reasonable way, you're doing this, um, again, uh, looking at the data you have available and making sort of objective decisions to, to track the market as best you can to confer with consultants in the industry, I think you will very likely have a defensible position that you are not making changes based on the volume or value of referrals, which is really the key concern. Even if you can't point to a applicable survey and say, with absolute certainty we are within fair market value, you at least ought to be able to build a good case that you're trying to set this in advance and you're not making changes to reward or penalized referral patterns. I think those are really gonna be key. Hopefully we will get some guidance from CMS or oig, you know, I, I don't have any reason to believe that, but, but other than just I think the industry may have a pretty significant outcry in, in, uh, and ask for it. Yeah. In terms of how are we supposed to do this in a compliant way in kind of the first half of 2021, which is the really highest risk shakeout time when there's not a lot of objective data and there's just a lot of, a lot of change in the market. So I think getting good counsel, good input and documenting that the changes you're making, um, have been reviewed and are not being not tied to volume values is probably gonna be good advice.

Speaker 3:

Yeah. And Rob, just the, um, put one little bow on that. Remember this is the only, only the first set or first category of ENM services that are being changed

Speaker 2:

<laugh>. That's right.

Speaker 3:

So, um, we could have years of this. Um, so we'll see how this plays out, but, um, but I, I like the, the idea that, um, that if you're not tying it to volume or value and that kind of thing that, um, that it, it, it shows your intent. Um, so I think that that that will, that will, I think favor, you know, being good favor for the provider.

Speaker 2:

Yeah. And ha you know, accessing valuators who are dealing with other folks in the market mm-hmm.<affirmative> and have some sense of what is happening in the market. Mm-hmm.<affirmative> is, is another, you know, it's another data point. If you don't have a formal survey, you're able to, at least I think this notion of talking to healthcare consultants who, and frankly healthcare lawyers who have clients who they then have a familiarity with how the system is being, how how individual players are, are changing things in response to these market forces is another good data point. Mm-hmm.<affirmative>, um, to, to just show that you don't have an intent to make the change as a result of volume value. Right. Um, that's the last topic, Valerie. Any, any final comments on that or generally before we wrap up?

Speaker 3:

No, I think we've covered it. I, I think we'll just see how this plays out with the final rule and any other, um, legislative changes, um, because we are in a, in a flux with Covid and all of that. So, um, it'll be interesting to see how this plays out, but I, I think we'll just need to stay informed and, and see how things go.

Speaker 2:

Totally agree and, uh, really appreciate the opportunity from HLA to speak on the topic. It is definitely timely and, uh, there's a lot, lot going on I in this area and obviously in the world. And, uh, we will, uh, we'll, we'll, we'll keep on top of it and, uh, look forward to helping, helping folks who, uh, need to navigate it. So thank you very much for listen.