“While few people are happy with the process, the ongoing mantra is ‘at least it’s a physician-driven system,’” Dr. Edelstein said, adding that many groups have tried and failed to replace the RUC. “It remains the single most-effective and least-expensive alternative for code valuation.”
The RUC represents the entire medical profession, with most involved direct patient care accounting for a high percentage of Medicare expenditures. The 31 voting positions are comprised of 21 ABMS members, with the remaining seats devoted to primary care, internal medicine sub-specialties, osteopathic, and AMA representatives. A two-thirds majority is needed to recommend a value.
The process to determine a code’s value begins with a survey completed by physicians of all involved specialties. The survey data is evaluated by RUC with final recommendations submitted to CMS, which publishes proposed and final rules annually. Historically the CMS has accepted about 90% of the RUC’s recommended values.
But things don’t always run smoothly, according to Dr. Edelstein.
“In 2016 we saw an atypical CMS overreach, creating cuts well beyond what the RUC already lowered. This was due in part to CMS’ misinterpretations and misperceptions about new technology, drugs, over-utilization, and excess post-op visits,” he said.
The AAO passionately and aggressively opposed these cuts, which would have resulted in decreases of 16% to 33% in the five affected codes through an appeals process known as “refinement.” Fortunately, CMS accepted the rebuttal, reversed the cuts and restored the proposed RUC values.