To the Editor:—

Williams et al.  1describe their technique of performing anesthetic procedures before operating room entry to decrease “anesthesia-controlled time” and costs. Unfortunately, the authors did not warn of the potential economic, fraud, and abuse problems that could result if other practices adopted their methods. While medically directing a case under Medicare rules, an anesthesiologist is not permitted to perform a nerve block in another patient (unless it is a labor epidural). If an anesthesiologist performs or supervises a block with a resident while medically directing care in the operating room, only 50% of the Medicare anesthesia reimbursement for that case can be billed because residents are not permitted to bill Medicare part B for their services.

In the practice of Williams et al. , 1this does not seem to be a concern because the mean age of their patients is 26.6 yr, suggesting that Medicare patients did not constitute even a small fraction of the patients in the study. Many other practices have significant amounts of Medicare patients, and issues of concurrency, reimbursement, and fraud and abuse must be considered when deciding whether anesthesiologists should start regional anesthesia procedures in a holding room while medically directing anesthesia care in other operating rooms.


Williams BA, Kentor KL, Williams JP, Figallo CM, Sigl JC, Anders JW, Bear BS, Tullock WC, Bennett CH, Harner CD, Fu FH: Process analysis in outpatient knee surgery: Effects of regional anesthesia and general anesthesia on anesthesia-controlled time. A nesthesiology 2000; 93: 529–38