Vachette Pathology

Many pathologists and laboratories are suffering from a simple lack of revenue management. Your payments will get worse if you choose to do nothing. You need to start auditing your billing and collection process and negotiate for more revenue.

Vachette Pathology is a pathology and laboratory practice management and hospital consulting firm. We currently manage over 50 pathology and laboratory practices coast-to-coast. They range from single man pathology practices to independent laboratories to 35 hospital based practices. Our Practice Managers have extensive experience in the field of hospital and laboratory billing. We can help to increase your revenue and secure your income.

Over the past few years we have seen more hospitals reduce the payment for Part A and Laboratory Medical Director Payments.  They state that these services are unwarranted and that the Laboratory Medical Director should be able to collect for any Part A services directly from the payers. 

This trend has me thinking back to 1996.  In 1996 the big buzz word in health care was capitation; this trend drove many hospitals and health systems to buy physician practices, which in turn led to an increase of the OIG investigating physician hospital relationships.

Recently one of our clients was approached with a RAC audit.  The auditors stated that the place of service (POS) of the pathologists did not match the POS of the hospital that billed for these services.  They stated that they were going back retroactively to 2011!  The auditors did not understand that the CR7183 TC Grandfather clause was still in effect and that it may be rescinded in July of 2012.  This is just another symptom of the current environment we are working with at this time.  The government is looking for every dollar and looking in every corner.  Many billers fought a tough fight with 5010 issues in January and many more will fight more battles on the 2407 issue and the upcoming changes in the TC Grandfather provision.

If your money from Medicare is down or non-existent this year, there are a multitude of reasons that could be keeping you from getting paid. The initial 10-day hold at the beginning of 2012 is long gone yet many physicians’ claims remain unpaid. The reasons run the gamut including system failures, mismatched clearinghouse submitter IDs, and even lost provider enrollment forms! The switch to HIPAA 5010 formatting aside, you may have issues you are not even aware that are holding up your payments from CMS. Clearinghouses are claiming the issues are systemic within CMS and that they are working fervently to resolve mass claims rejection problems. But since the issues are rooted with MACs and CMS overall, the clearinghouses have no choice but to wait for solutions.  Even if you are lucky enough to get through to CMS, who is experiencing triple the call volume already this year, you may be left with more questions than answers.

As you know, the formatting for electronic claims submission changed effective January 1, 2012. The change required additional required fields and updated programming for vendors and information technology gurus. That date has come and gone… and there are issues.

While CMS is up and running relatively smoothly, there are many carriers and clearinghouses that continue to have trouble accepting the new format. CMS was smart about this change: they began ‘testing’ files with vendors during Q4 2011 and approved only those vendors whose updates met the new standards. It appears that most are submitting electronically to CMS with little to no difficulty. Commercial clearinghouses, the Blues, and direct carriers appear to be the culprits of the unpreparedness we are currently facing with the electronic submission changes.  Maybe they thought that the change wouldn’t happen or the deadline would be delayed. Either way – that didn’t happen and now they’re scrambling….

If your cash is down this month, circle back to the very beginning of the electronic billing process: the electronic submission.

1.       Is your vendor (billing agent, software, clearinghouse) up and running?

2.       Have they tested their files and been approved?

3.       Are they watching for file acceptance or rejection?

Remember that the absolute deadline for 5010 formatting is March 31, 2012. If the programming is not completed and accepted by that date, your cash will stop completely.

There are several issues on the table for 2012:

• The pay cut for the 88305-TC
• The SGR 27.4% pay cut across the board
• RAC Audits
• ACO’s

Let’s take a look at how these will affect us: 

The pay cut for the 88305-TC is most likely going to take place. This CPT code has been increased steadily since 1996 also there has been a tremendous increase in the volume of this code by non-pathology groups.  With these biopsy volumes spinning out of control everyone is calling for a halt.  The best way to do this is lower the payment which in turn will decrease motivation.  Let’s play this out a bit.  If this CPT code is lowered many non-pathology groups will see their margin wither and die: this work may then return to both hospitals and independent labs.  Whether or not they can make a margin doing this work becomes their problem.  That is a whole different issue.  The good news is that many hospital based pathologists will find their work load increasing.