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AHLA's Speaking of Health Law
The Impact of Split-Shared and Other Billing Concepts on Fair Market Value
The split-shared rules have recently changed, causing confusion. In addition, CMS made clear in recent commentary that Medicare billing rules should not be conflated with the rules under the physician self-referral law (i.e., Stark Law). Angie Caldwell, Principal, PYA, and Jana Kolarik, Partner, Foley & Lardner LLP, discuss what split-shared billing is, how the rules have changed, and how they are advising their clients on issues pertaining to valuation and fair market value. Sponsored by PYA.
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Speaker 2:On behalf of p y a, I would like to welcome you to this episode of a H l A speaking of health law. My name is Angie Caldwell. I am a principal with p y a, located in the Tampa, Florida office. I'm the managing principal of this office. I have about 30 years of healthcare experience, including about 12 years of compensation valuation experience. And it's my pleasure to introduce you to my, my friend and colleague, Janet Clarkk, uh, who will be speaking with me today on this awesome topic, uh, regarding split shared visits, personally performed service, and how all of that has become really confusing in today's environment, uh, as it to physician compensation as well. So I'm gonna turn things over to and allow her to introduce herself and let's talk.
Speaker 3:Sounds great. Thanks so much for inviting me to Angie. This is, it's always lovely to talk to you. So, and h l a is a great organization, so it's nice to be talking to you on this. So, um, I, as Angie had mentioned, my name is Janna Klark. I am a partner with Foley and Larner. I am primarily in the Jacksonville, Florida office, although I do claim DC as well, because I worked there for a long time. I am a healthcare compliance lawyer and, um, have been doing healthcare law for a little over 20 years. So it's great to be here with you, Angie. And I think I'm gonna set up kind of the landscape of split shared, uh, billing, which has become very, very confusing in the last year or so. Um, so c m s has, um, is moving the target a little bit or moving the ball a little bit with regard to split shared billing. Um, and what split shared billing is, I should start with that. Um, it's, uh, evaluation and management or e and m service that's performed jointly between a physician and an advanced practice provider and a p p, like a nurse practitioner, for example, or a physician assistant. And it's build under the physician's national provider provider identifier, N p i, at a hundred percent of the Medicare physician fee schedule rather than 85%, which it would be if it were billed under the apps npi. So that's kind of what split shared billing is, um, sort of in a nutshell. But what's happened is over the last year plus really is that they've, they've changed the rules a bit. So with the concept of eventually going to more of a time-based situation, um, CMS has, has tried to make the, what ramp up a little easier. Um, I think although it's been a bit confusing by, um, allowing the physician to provide essentially one component of the E N M service or do more than 50% of the time in order to bill it under the M P I. Um, what that means is the physician can do the history, um, document it, they can do the physical document it, or they can do the medical decision making and document it and get credit and, and bill under their npi. Um, what's been confusing is that there's a concept of substantively performed, um, which I think people understood to mean sort of more than 50% of the service was performed by the physician. But you can see that kind of, these concepts of performing one component, is it really 50% maybe? Um, so there's been, there was prior guidance that spoke about, you know, the physician performing overall more than 50% of the service. And so those two concepts seem to have been conflated a little bit in some of the contractor's guidance. Um, c m s guidance is pretty clear, and that is what I said originally, but that, you know, that, um, those issues have been sort of confusing. Um, the other confusing part is this whole thing has been for this year, and C M s, um, has extended it through 2023. So we're living sort of under a little bit of this confusion for next year as well. So for our purposes, I think the billing part of it is, is the confusing part. And, and we've spoken about that before. Um, I think where we pick up frequently is kind of how this affects us from evaluation perspective. What is the physician sort of getting credit for from a W R B U perspective sometimes, um, if the physician is actually paid on that basis, how much of that W R B U should the physician get if they're performing a portion of the service? And so, Angie, I'm gonna kind push it to you a little bit cause I've been talking for a long time and kinda get your thoughts about our discussions and you can outline it and then we'll go back and forth about how that affects from evaluation perspective and conversations that you may have had with some of your clients on that.
Speaker 2:Right. So we have all of these changes and the rules and the guidance around split shared visits. And at the same time, CMS and some of their guidance also provided commentary around personally performed services. So if you think about the nature of a, of a split shared visit, it's a collaborative service between a, a physician and an advanced practice provider. So then from a billing perspective and that billing compliance perspective, you can, um, follow the rules and make sure that the, the time is attributed to the right provider or perhaps the, the medical decision making. And that piece of it is attributed to the correct provider. But then the next step of that is to push it through to how that impacts the compensation plan and how that physician, and perhaps also the a p p, how, how they're are compensated. So Jay, and I know you and I have talked about the prevalence of the work RVU model, the productivity based model, um, and it, it's the predominant model that we see, uh, of an, a hospital employed physician, about 70% of hospital employed physicians are paid on a, on a work RVU basis, and which is great, we all love the work rvu, right? It's, it's easy to measure, you can track it, the physician understands and knows what it's, it's me, it's well measured and documented. There's a lot of thought process into determining the work effort surround surrounding that C P T code. And it's, it's a, it's a wonderful measure. But of course what has happened along the way and what, you know, what we're all trying to do is we're trying to get away from, you know, paying for per service to more of an outcomes based or a quality based, but the physician is still paid on a, on a productivity based model. So they are, are incentivized, if you will, to, um, look at the work vus and look at how the work vus are being attributed and how they're accumulated, and then of course, how they're paid. So thinking about that and then thinking about what's personally performed.
Speaker 3:So let's back up for a second with regard to that. So let's pause on the personally performed concept, because that is something sort of separate from the billing rules that's present in the Stark Law. And so the concept of personally performed services and paying physicians for personally performed services, um, is one that was really emphasized sort of within the last couple of years as well. I mean, that's something that, you know, as you're sort of looking at not paying for referrals and paying people for, you know, what is fair market value, what does fair market value mean? And, you know, looking at those personally performed services CMS size, that what's happened, um, I think over time, um, is the billing rules, which we've been talking about and the Stark law rules have been conflated a bit. And so those W R V U components, which, you know, maybe bill under the physician's NM p I number, but may have been, as you said, collaboratively performed. And so not completely personally performed that that's one thing that's on one side of it, but that you really need to be thinking or, um, I think the, the guidance that I heard loud and clear within the last couple of years is you really need to be thinking is you're setting physician compensation to not just assume that what's been billed under that physician's MPI is what you should attribute to the physician for purposes of a compensation that you should really think through that concept. So that's what we're talking about here. And I just wanna kind of make clear when you're talking about the other CMS rules, which talks about first under reform that we're on that side of the ledger, so to speak. And that really being careful has, as we all know, under the Stark law, broad ramifications from a, from a strict liability perspective as well as from a penalty perspective if you don't quite do it right. So anyway, I just wanted to set that up a little bit before you continued the discussion.
Speaker 2:Exactly. So let's talk a little bit more. So we set up, we started the conversation with the split shared
Speaker 3:Guidance mm-hmm.<affirmative>
Speaker 2:Mm-hmm.<affirmative>. And so let's just think through an example for a moment of a, of a typical split shared visit and with the delay and the time-based mechanism.
Speaker 3:Yeah.
Speaker 2:2023 for billing. Um, then, then we have, there are certain, certain, uh, criteria then that, that are met. Um, in, in that split shared visit, again, understanding how it typically works in the hospital setting. Part of that visit is performed by a physician, and part of that visit is performed by the A P p, likely with the A P P spending more actual time with the patient than, than the physician, although the physician might ultimately be responsible for and document the medical decision making. Mm-hmm.<affirmative>. So again, so while that's, that's billed under one C P T code and billed compliantly under the one code, then as we go to the other side of the ledger to use your, your phraseology, if we go to the other side of the ledger, bill compliantly, but then from a compensation perspective, how do we break that out, if you will, into what is personally performed by the physician and what is not?
Speaker 3:Because what you're saying too, and just to kind of add on to that, is the physician's, N P P I, is the one showing as the build billing provider. Right. Rendering provider also. Right. Because the physician is doing the majority of the component or that and that medical decision making component, which is important at this point in time in order to build a service. But at this point in time, because we don't have the time, we have no real sense of how much time was spent. And to your point, the a p p, the N P or the PA could have spent a lot more time on that component. And so from a billing perspective, if you're pulling data of, for W R V U purposes from your billing system, your claim system, which makes sense, you're showing the physician builder, the physician's, the rendering provider, how do you break down how much of that the physician Did you tell me, how do you do that?
Speaker 2:Right. It's very difficult. Cause you can't see it. You can't see it, the, the data because the physician is showing as both the, the billing it and the rendering. So the only way to know who did what would be to look at some medical records, dig down and to, to see who document, who documented what in the chart at what, at what time, and to what extent. Um, to get an understanding of how that particular physician works, um, and how how much they collaborate with the apps, what their schedule normally looks like. It's very difficult to do.
Speaker 3:Yeah.
Speaker 2:And so what ends up happening then is that in a normal productivity based model, then you understandably, all of the codes and all of the work vus are attributed to the physician. And then, you know, then we get into the question of the valuation for that. Right. Right. So,
Speaker 3:Right.
Speaker 2:What, what is considered fair market value and what component of the service is personally performed versus, versus not. Uh, again, very difficult to do, very difficult to determine. Um, and,
Speaker 3:And what if you also have the, the A P P being supervised, well being supervised by the physician, let's just assume that, and, and the physician also being paid some stipend for that supervision. How does that, how does all that sort of join together? I mean, I assume, and we've talked about, right? I don't assume this is what you've told me. So let's be very clear that you can't, right. It's not wrong to give a portion of the WRB use for credit for that supervision. Right? Right. But in totality, it seems like that's not personally performed because at that point you're going beyond maybe what is supervision to really sort of attributing the performance of it to the physician. So how does that play out from an what have you seen sort of from a numbers perspective or how have you tried to orient your clients related to fixing some of those arrangements where all those w views are flowing to the physician and the physician, frankly, maybe, um, supervising multiple apps, so we're not talking one a p p in certain circumstances. It can be two three multiple Right. Sort of dependent on state law. Yeah.
Speaker 2:Right. One, one thing that we try to do, um, to, to demonstrate that the impact of this is to look at what is a typical value for a p p supervision from a dollar's perspective in the market, and look at a pot comparing that then to a potential impact of what is being attributed to the physician, which might not be personally performed. And looking at the dollar impact between those two. And like you said, Janna, the, you know, the question is, is the value being attributed within the work rvu? Is that for supervision? Is that fair market value? Because there isn't any, it's okay to attribute some portion of that to the physician for supervision. Supervision of the work is a personally performed service. Mm-hmm.<affirmative>, that's something that the, that is a value that the physician is providing, but the val is the value of that supervision fair market value mm-hmm.<affirmative> and looking, looking at that difference and, and looking at that comparison. And sometimes it can be eye-opening, um, you know, to, to think through that. And it's that that variance and that impact, if you will, is going to be different depending upon the specialty and depending upon the level of collaboration. Uh, and so many other, so many factors. So it would be difficult to say that on, you know, on average the impact is X percent
Speaker 3:X mm-hmm.<affirmative> mm-hmm.<affirmative>.
Speaker 2:Um, so while we, it, it would be difficult to do because there are so many variables that come into to play on a, on a specialty physician basis.
Speaker 3:Yeah. But you've seen some extreme examples from a percentage basis. Like just throw out some numbers, sort of in worst case scenario kind of what this, and I assume right, that what we're talking about sort of where it can, can, can get, um, the numbers can get quite high, is really sort of in the proceduralists where you're dealing with maybe a physician who's a very active surgeon, who may have multiple apps who are doing a lot of the office, the clinic base work, which Right. Freeze that him or her, that physician up to do those surgeries, which is frankly best use of time in a lot of ways. But gimme some, gimme some numbers. Like, I mean, I don't, and not like I don't need dollars, but gimme some percentages. If you can think of off the top of your head. Cause I know I'm sort of throwing this at you out of the blue.
Speaker 2:So hos Yeah, absolutely. The hospital based physicians, based upon some of the studies that we have done, the a PPP impact on work, VUS would range probably anywhere from 10% mm-hmm.<affirmative> to perhaps 20 or 5%. Yeah. We're in a state of change right now. Right. Within rules, we're in little bit of a state of change and you know, we have some physicians now feeling the impact of that and even questioning their use of an ap
Speaker 3:Mm-hmm.<affirmative>, they
Speaker 2:Know that that will impact perhaps their work vu volume and impact their compensation. So we're in a little bit of a state of flux, but that's what we see on, on the hospital based provider side. Thinking about the proceduralist, the surgeons that, that you mentioned and you asked about, so let's talk about that a little bit more in a little bit more detail, because the surgeon also thinking of, again, personally performed, personally performed services, the surgeon will have the impact of, and the leverage of an A P P as it relates to globally built service
Speaker 3:Mm-hmm.<affirmative>. That's right.
Speaker 2:So they would not only, so they could have a, a split shared impact and they could also have a mm-hmm.<affirmative>, a globally built service impact. Yeah. So again, can't see the impact of that billing report.
Speaker 3:Right. And let's explain that a little bit. So that's pre-surgery, post-surgery clinic time. That may happen when the patient comes in to, to, to see the A P P prior to having the surgery, gets everything sort of set up. And then again, they bill it as a, as a global surgery code, which again, from a W R V U perspective is intended to incorporate not only the surgery work, but also the pre and postsurgery work as well. So that's what you're talking about when you're talking about the global surgery.
Speaker 2:Exactly.
Speaker 3:Got it. Exactly. Important to remember.
Speaker 2:And our, we want those physicians to leverage their apps appropriately.
Speaker 3:Sure. Yeah.
Speaker 2:And because the physician, those highly, uh, highly productive surgeons, of course, they're spending the time in the, in the surgical suite mm-hmm.<affirmative>, um, doing surgeries. So they're leveraging and utilizing those apps, especially to do that, that postop work, the postop follow up, um, after the procedure. So again, of course all of that on a, on a billing report and from a work review attribution perspective, the billing and the rendering provider is the same.
Speaker 3:Yeah. It's always the It's the physician. Yeah, exactly. The surgeon, yeah.
Speaker 2:Very hard to, to determine, uh, what is not personally performed by the physician. Again, some of that supervision mm-hmm.
Speaker 3:<affirmative> Sure.
Speaker 2:We understand that. But the, back to the original question that you asked Yeah. Related to percentages on a proceduralist basis mm-hmm.<affirmative>, uh, we see anywhere from a 10 up to a 35% Yeah. Impact. So in work vus, uh, related to that, to the leveraging of, of an P. Yeah. So again, thinking about what truly is personally performed, what truly is supervision mm-hmm.<affirmative>, what truly is the value of each of those components needs to come into play. Yeah. Yeah. And, and compensation valuation can be billing build all day long. That's right. But from a compensation perspective, do we have it, do we have it, um, thought through completely Yeah. From a personal perform perspective. Yeah. And then the only other specialty group, Jan, that we haven't talked about yet is our primary care physicians.
Speaker 3:Yes.
Speaker 2:And how perhaps this impacts them. So, and of course when I say primary care, I'm not just talking about our, our family medicine and family practice friends, I'm thinking about our rheumatologists, I'm thinking about our endocrinologists, I'm thinking about other, um, other primary care type specialties. So of course this specialty is a little bit different mm-hmm. That we're not, not as much in the hospital space. Correct.
Speaker 3:Right.
Speaker 2:So much less likely to have a, a split shared billing scenario and collaboration with an A P P that way. Um, that would impact, um, work RVU accumulation and attribution
Speaker 3:Mm-hmm.<affirmative> mm-hmm.
Speaker 2:<affirmative>. So really if for a primary care type physician, if you can split out the incident two services, right. Which are truly performed by the advanced practice provider, the work RVU attribution should be. And it's here to determine, uh, what piece is personally performed. And Janna, one thing that we haven't mentioned, and I dunno if you wanna comment upon this further, but this of course is we're not talking about a group practice here.
Speaker 3:Right. No, I think that's important from, I was thinking that as you were talking about a group practice. If, if you have a, and this is under the Stark Law, the group practice standards under 42 CFR four, 11.3 52, if you have a group practice and you know, your practice meets the group practice standards, which are many and, and sometimes difficult to meet. But if you do meet in and you meet the exception under the office ancillary services exception, then talking really about personally performed in this attribution, she becomes, is, is frankly not an issue. If you can meet those, those standards because you can split, um, profits a bit differently, um, there's just more flexibility. We're really talking more about trying to meet the employment, um, exception under Stark and really even the indirect compensation exception where you're dealing with and Yeah. So that where you're dealing with FM B and you're trying to figure out it was this personally performed, um, to try to get to the right number for these guys. Um, and guys I use loosely as men and women. So apologies to all of those.<laugh> don't, don't, don't mean to be particular, but yes, it that. Yes. And thank you for, for raising that. So that is sort of a caveat to kind of put in the back of your head, but a lot of times, um, you know, my experience has been that health systems are really trying, they would love to meet the group practice standards. They would love to be able, and so they do try, but frequently don't, they fail to meet one of the standards, and so they fall outside of it. And in that instance, you really do have to be careful, um, and really look at this from an FMD perspective and from a personally performed perspective. So all these things come into play.
Speaker 2:Yeah. And so one of the things that, other than considering the group practice exception mm-hmm.<affirmative>, one of the things that some of our, our clients are, are considering related to this issue mm-hmm.<affirmative> and just relating to, you know, how how do we align our compensation model and plan with, with fair market value, and how do we structure it appropriately, so mm-hmm.<affirmative> so that we don't conflate the right billing guidance with this stark guidance. How do we do that? So one of the things that we're starting to see a lot of here is that, um, folks are starting to consider moving away from a productivity based model. Yes.
Speaker 3:Yes.
Speaker 2:In the ho especially for hospital based
Speaker 3:Providers.
Speaker 2:Yes. Um, which again is a, is a shock, uh, to the, to the provider because they've, they've become accustomed and they've become quite fond of that work RVU for all of the reasons that we talked about a few moments ago. Mm-hmm.<affirmative>, it's measured, it's tracked, it's, you know, it's well known. Um, and so, but moving, moving them away mm-hmm.<affirmative> from that model may be a great option to eliminate this concern Right. About, about who's doing what.
Speaker 3:Incorrect attribution. Yeah, exactly. Well, let's talk about that for a second, because then, and again, you know, we've talked about it, I've talked about it with other valuation consultants as well. Frankly, it seems like the W R V model from, um, from a hospital-based physician perspective, sort of an odd model to have adopted into that space. You know, my understanding, cause I'm just dealing with ED physicians and hospitals in in particular, is that it's, it's almost like they saw that this was happening and they thought, oh, that's nice, let's do that. Um, but it doesn't, they have no control over the flow of patients. It's what they get. So it's a very, it's, um, you know, in, in my understanding, and you tell me because this is your space that the W R V U model was really intended to get, you know, even primary care physicians, but also, you know, surgeons to get throughput, um, you know, to incentivize sort of seeing patients and, and getting them seen. Um, which anyway, you tell me about like how this even happened, that we're at this place where we're trying to unwind something that maybe should have never happened in the first place. Right,
Speaker 2:Right, right. And I, and I think it started out with good intentions mm-hmm.<affirmative> where, um, employers were trying to ensure that physicians were productive. It's a measure productivity. Right.
Speaker 3:Said
Speaker 2:It's a measure of, of throughput. But to your point, these hospital based providers aren't, aren't very much in control of no throughput in many cases. They are, are taking what comes to the door and, and having to, having to deal with that. And so I, and two, I think from a, from an administrative simplicity perspective mm-hmm.<affirmative>, that, that became when, when we had the shift historically from many more, we had a larger group or a larger practice, larger population if you will, of independent practices. Mm-hmm.<affirmative>, more and more physicians became employed. Of course, there was a struggle then to figure out how, oh my heavens, how do we administer all this compensation? So there was a desire to implement a simple structure. Got it. Got it. One could be easily measured, one that could be replicated.
Speaker 3:Got it.
Speaker 2:Multiple specialties. Mm-hmm.<affirmative>. So low and behold, we have the structure which might not necessarily align. And so the, the trend today is to align the compensation structure with how the physician works. So if the physician is a coverage based physician, and then perhaps the compensation model is best aligned with a coverage based model
Speaker 3:Versus a productivity model. Gotcha. Makes sense. Makes total sense.
Speaker 2:So we're seeing
Speaker 3:So you're seeing a shift.
Speaker 2:Yes. Yes. We are. And even with primary care. So primary cares very interesting. Right. Because you think of primary care as a patient in patient out. Right, right. Easily, easily want to, to me wanna measure productivity of the practice, but with primary care, because they're at the foundation of, of the patient. Right. And they, it's more becoming about panel management. Yes, yes. Panel side.
Speaker 3:Yes, yes. As
Speaker 2:Well as outcomes.
Speaker 3:Yep.
Speaker 2:And so we're even starting to see a shift for primary care. Uh, it's, we're at the beginning of it, but we're seeing it more panel size and outcomes instead of work RV
Speaker 3:Productivity. Which is nice though. I mean, cuz when you think about it, it's more sort of care focused than it is sort of the throughput focus.
Speaker 2:Yeah. Yeah. Think about our, where we started. Yeah.
Speaker 3:And
Speaker 2:This conversation, let's back little bit and, and recap, because we started about billing rules
Speaker 3:Mm-hmm.<affirmative>,
Speaker 2:Which shared and the guidance and the, the confusion around the
Speaker 3:Guidance. Right.
Speaker 2:Because that guidance informs billing compliance
Speaker 3:Mm-hmm.<affirmative>
Speaker 2:And that billing compliance is contingent upon who's doing what.
Speaker 3:Yes. Agreed.
Speaker 2:In the split shared setting. Yes. So then that's one, um, I'm gonna go back again and use your side of the book.
Speaker 3:Yeah, yeah.
Speaker 2:So on that side of ledger, that's one piece of this puzzle.
Speaker 3:Mm-hmm.<affirmative>,
Speaker 2:Then we took that and we said, okay then from from that, how does Stark
Speaker 3:Mm-hmm.<affirmative>
Speaker 2:Think about this from a personally performed perspective
Speaker 3:Mm-hmm.<affirmative> mm-hmm.<affirmative>.
Speaker 2:And so then we picked up the other side of the ledger and we said, well, from a stark perspective, here's how Stark would think about split shared, or
Speaker 3:Perhaps mm-hmm.
Speaker 2:<affirmative>. And here's what's happening with a split shared visit. Yeah. And so we talked about hospital based providers, but I think that's the key, that transition that you and I made in this conversation between billing mm-hmm.<affirmative> to compensation plan compliance and that transition is the one that we all need to be thinking about.
Speaker 3:Yes. Yes.
Speaker 2:Cause both sides of the ledger need to be in balance to achieve complete compliance.<laugh>
Speaker 3:Yes. Yes.
Speaker 2:Instead of just, just one side compliance. So then we backed, so we made that transition and we mm-hmm.<affirmative> split shared services personally performed pieces as part of that split shared service hospital based physicians. We talked about proceduralists and
Speaker 3:Surgeons
Speaker 2:Mm-hmm.<affirmative> and how personally performed aspect and split shared impacts them mm-hmm.
Speaker 3:<affirmative> as
Speaker 2:Well and how that should, how folks should be thinking about that from a compensation and valuation compliance mm-hmm.<affirmative> from our
Speaker 3:Mm-hmm.<affirmative> perspective.
Speaker 2:And then we talked about our primary care
Speaker 3:Folks mm-hmm.
Speaker 2:<affirmative>. So I'm gonna throw another thing in here.
Speaker 3:Okay.
Speaker 2:To close out the loop from, because we talked about so many different providers.
Speaker 3:We did. Yeah.
Speaker 2:We didn't talk about the A P
Speaker 3:P. Ah. Yeah. So
Speaker 2:What if your a p is compensated on a productivity based model?
Speaker 3:How frequent is that though?
Speaker 2:Becoming more frequent instead of less frequent? If you can believe
Speaker 3:That. Interesting.
Speaker 2:So think about that. So if you have a hospital based a p p that all of a sudden is getting paid on a productivity perspective, this discussion can impact that compensation plan because what's being attributed to the A P P and not mm-hmm.<affirmative> the physician, um, is important.
Speaker 3:Yeah. So Yeah. And you worry about double counting or correctly count. I mean obviously correctly counting, but also double counting, um, in that scenario too. Yeah. What's interesting too, and one of the things that I kind of wanted to note, not to throw a whole wrench in all of this, but how are the valuation reports doing with all of this survey is doing with all of this data? Are they, I mean, I think the systems are having trouble, hospitals are having trouble or would have trouble sort of parsing this stuff out. How are the evaluation surveys doing with parsing all this stuff out? Have they really even sort of delved into this? I mean, is this a focus of theirs? What do you think?
Speaker 2:So the, the surveys are, and, and Janet, you and I have talked about this, the surveys are, are great.
Speaker 3:Yeah. They
Speaker 2:Provide a, a valuable resource to, to all of us with respect to the data that they accumulate. But as we've also discussed, there's no guarantee that the information going into those surveys has been modified or adjusted as it relates to work our big, big attribution and these issues. Exactly. Yeah. And so I, I'll point out, uh, for anesthesiology, and that's is a specialty that's totally different than all of the ones that we've spoken about today. Mm-hmm.<affirmative> surveys, certain of the surveys do provide guidance the respondent to the survey about how you should report C RNA productivity with respect to AA units.
Speaker 3:Nice.
Speaker 2:I do hope that, you know, hope in the future that the surveys will also start to consider some guidance to the respondents about mm-hmm.
Speaker 3:<affirmative>,
Speaker 2:About a p p collaboration with the physician.
Speaker 3:Yeah.
Speaker 2:Cause when we look at the work RVU totals
Speaker 3:Mm-hmm.<affirmative>, especially
Speaker 2:In surgery service, surgical specialties, when you look at those work RVU totals, you can't help but, and knowing the time, the time associated with those work RVU and CCPT codes, which is published in a and available for us to see and study that. When you look at those work vus, you can't help but to think that there's a p p service embedded in those totals
Speaker 3:Mm-hmm.<affirmative> in
Speaker 2:The survey data.
Speaker 3:Yeah.
Speaker 2:And so then we, when you look at the survey data, you have to understand that it's a starting place.
Speaker 3:Yeah.
Speaker 2:And that it could perhaps have some mixing and matching of, of productivity within the physician reported data.
Speaker 3:Yeah. That's fair. That's fair. Well, I don't, this has been as usual an incredibly interesting conversation. We've covered a lot of ground, right? Mm-hmm.<affirmative> from the billing rules to the physician self-referral slash claw rules to valuation zme. So thank you. Thank you for inviting me.
Speaker 2:Thank you, Jan. I'm so glad you're here today. Thanks to a H L A for, allow us to get together to speak on this topic today, and hopefully we'll get a chance to do it again. My pleasure. Yeah.
Speaker 3:Love it. Thank you so much.
Speaker 2:Thank you.
Speaker 1:Thank you for listening. If you enjoy this episode, be sure to subscribe to a H L A speaking of health law, wherever you get your podcasts. To learn more about a H L A and the educational resources available to the health law community, visit American health law.org.