In 1982 the Health Care Financing Administration (HCFA) that later became know as the Centers for Medicare and Medicaid (CMS) revised the conditions of participation for ambulatory surgical centers (ASCs) to require physician supervision of CRNAs and in 1986 revised the conditions of participation for hospitals to require supervision of CRNAs.
What are “Conditions of Participation”? These are the conditions that ASCs and hospitals must meet for reimbursement for providing services and care to Medicare patients under Part A of Medicare.
In 1990, the President of a state nurse anesthetist association wrote a letter to HCFA regarding concerns about the federal supervision requirement and requested a definition of the term “supervision”. HCFA responded with a general definition of supervision and a policy interpretation. This lead to many meetings between HCFA and the AANA in which AANA requested that the physician supervision requirement be dropped, and that the federal government defer to the states.
In 1994, legislation was introduced in both the House and Senate providing for fair anesthesia payment and deferral to state law on the issue of physician supervision. Also in the fall of that year, HCFA issued draft regulation in the Medicare Conditions of Participation for Hospitals which includes the removal of physician supervision of nurse anesthetists.
During 1995, AANA continued to inquire of HCFA when the regulations would be released and members continued to lobby Congress for direct reimbursement and removal of the supervision requirement. Bills were introduced for removal of the supervision requirement, and direct reimbursement for CRNAs, but were not included in the final Medicare package. In 1995, direct reimbursement was passed to become effective in 1998, but the supervision issue remained unresolved.
In December 1997, HCFA issued a proposed rule deferring to the states on the supervision issue. A comment period was held, and AANA members continued to lobby Congress during the Mid Year Assemblies.
On January 18, 2001, two days before President Clinton was to leave office, HCFA and HHS published the rule to defer to the states in the Federal Register. The rule was to go into effect March 18, 2001.
March 18, 2001, President Bush freezes the rule for 60 days pending further review. May 18. 2001, the Bush Administration freezes the final rule for 180 days and suggested a new rule be issued that would permit state governors to request a waiver from the Secretary of HHS and require a study of anesthesia outcomes. There was a 60 day comment period and the final rule on Opt Out was final on November 13, 2001.