Payment Policy Subcommittee Seeks Collaborative Working Relationships with Health Plans

November 21, 2008


By Joel Kaufman, MD, FAAN, Chair, Payment Policy Subcommittee

joel kaufman

The mission of the Payment Policy Subcommittee of the Medical Economics and Management Committee (MEM) is to foster positive relationships with the health insurance industry in working together toward health care solutions, and to establish itself as a primary point of contact for members and payers seeking policy definition and development. This has become a new area of focus for the Academy in 2008. Once the MEM became a full committee, with sufficient resources to allow it to establish subcommittees, it was possible to pursue these activities, which are new to the Academy.

With the development of the Payment Policy Subcommittee, the Academy committed to creating formal working relationships with health insurers.

But it’s not just the Academy that has benefitted from positive working relationships with the insurer community: Payers have also recognized the importance of collaboration with specialty societies as conduits to subject matter experts who can help them in a number of areas. Increasingly, health plans around the country are asking us for input on their medical policies.

The Payment Policy Subcommittee is frequently asked to comment on policies that require specific subspecialty expertise. Because the subcommittee itself is quite small—with only seven dedicated members—it reaches out to subject matter experts, typically through the executive committees of the appropriate Academy section(s) for input and review. The subcommittee developed an informational white paper to explain the process to section members who are asked to assist in reviewing a policy. This paper is now available on the sections’ individual areas on

When the Centers for Medicare and Medicaid Services (CMS) releases a proposed regulation or rule, Payment Policy takes the lead in responding. Not only does the subcommittee ultimately submit all of the Academy comment letters to CMS, but it also facilitates face-to-face meetings to discuss pressing issues. In the spring of 2008, Payment Policy and the Academy’s Stroke Systems Work Group (SSWG) met with CMS regarding discrepancies in payment for stroke patients who receive tPA at one institution and are then transferred to a different stroke center. CMS gave us information on how to obtain the right data to make our case strong enough for them to reconsider their policy. This led to the creation of a new ICD-9 v-code for hospital billing staff to use when this scenario occurs (V45.88 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility. Code first condition requiring tPA administration, such as: acute cerebral infarction (433.0-433.9 with fifth-digit 1, 434.0-434.9 with fifth digit 1) acute myocardial infarction (410.00-410.92).) The new code allows CMS to track exactly how many patients fall into this category, and they may make more appropriate reimbursement decisions in the future.

The Payment Policy Subcommittee also monitors, tracks, and acts on important payer issues as they arise. Recent actions taken by the New York Attorney General prompted Payment Policy to develop an Academy position statement on principles that should be required as part of any insurer physician profiling program.

The Payment Policy Subcommittee was quick to respond to member requests to develop a model medical policy outlining coding principles for intraoperative neurophysiologic monitoring (IOM). Once developed, Payment Policy Subcommittee members contacted various insurers to urge its adoption. Highmark Services (Medicare Carrier) now cites the Academy document in its “Sources of Information and Basis for Decision” section. The Payment Policy Subcommittee has discussed this model policy with other payers as well.

We are highly encouraged by our growth and positive interactions with many of the large, national payers in our inaugural year. We look forward to future projects. Please contact our staff liaison, Katie Kuechenmeister, by email at or by phone at (651) 695-2783, with any questions, concerns, or issues you would like the committee to discuss or review.

Author Disclosure

Dr. Kaufman has nothing to disclose.