Posts made in 2005

Two New CPT Codes for Touch Prep/Squash Prep

Posted by on Dec 15, 2005 in Latest News | Comments Off on Two New CPT Codes for Touch Prep/Squash Prep

We have noticed two new Pathology CPT Codes appearing in the billing mix. They are as follows; 88333 – Pathology consultation During Surgery: Cytological Examination (initial site) 88334 – Pathology consultation During Surgery: Cytological Examination (ea. add. site) We have set the price on these two codes at: 88333 – $120.00 88334 – $100.00 If you are billing these new codes and are not being properly compensated for them by the carriers you deal with, or your billing company is not properly entering or billing for these codes, we at Vachette Pathology can help. For more information, please contact Mick...

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More Financial Challenges for Pathology Practices in Michigan

Posted by on Dec 5, 2005 in Latest News | Comments Off on More Financial Challenges for Pathology Practices in Michigan

Effective January 1, 2006; PPOM’s network in Michigan will replace Aetna’s networks for most Aetna plans and products. PPOM was acquired by Aetna as part of HMS Healthcare purchase. In July 2005, Aetna completed its acquisition of HMS Healthcare, the parent organization of the PPOM and Flora Health Networks. If you are participating with PPOM, you will now be paid the PPOM rate for all of your Aetna patients. This may cause a payment decrease as typically Aetna was paying more per 88305-26 then PPOM. We have also discovered Connecticut General Life Insurance Company (CIGNA) and Health Alliance Plan of Michigan (HAP) have formed a marketing affiliation to jointly offer a suite of open access products to companies with operations in Michigan and other states. The products will be offered through CIGNA and HAP’s subsidiaries; Preferred Health Plan Inc., Alliance Health and Life Insurance Company. Many practices are looking at other options to stop this network shifting that leads to declining revenue. Vachette Pathology is helping nine separate practices in Michigan to re-negotiate their managed care plans and actually increase their revenue. For further information, please contact Mick...

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The Basics of Auditing Your Pathology Billing, Part 2

Posted by on Jan 5, 2005 in Latest News | Comments Off on The Basics of Auditing Your Pathology Billing, Part 2

In our first installment we discussed the issues surrounding charge capture and insuring that all of the work you perform is actually billed.  This article will cover the topics of fee schedules, sliding fee schedules, client billing and the various types of billing that can be involved.  The next article will include strategies for revenue generation including, part A negotiations, managed care contracting and marketing options. During any audit process it is always necessary to review the client’s fee schedule.  Even in this time of managed care agreements and “allowed amounts” there are still numerous reasons to review the fee schedule. The first thing audited is the type of work performed.  Do you perform your own Bone Marrow biopsies?  Are these included on the fee schedule?  Does the group pull their own FNAs and are these included on the fee schedule?  What about the adequacy code for FNAs?  What about the new code covering Bone Marrow Aspiration?  I still find a fair number of groups that have missed codes in their fee schedule. Finally I always look at the blood bank codes and the Medicare clinical codes.  Again numerous groups have told me they are compensated for all Medicare work through their part A agreement, and are not even aware that these codes are billable. Next I review the group’s fees.  Are they fair and adequate?  Are some fees too high or too low?  What is a fair fee?  In some areas this fee may be three times Medicare and in another area this may be very low.  Remember the fee schedule should be based on what the payers are willing to pay.  Why have fees that are lower than the payers allowed amounts? Many groups have a discounted or sliding fee schedule.  This is a fee schedule where there are discounts placed on a CPT price by volume.  For example: 88305-26 1 to 5 = $200/each 88305-26 6 to 10 = $150/each 88305-26 11 and above = $100/each The key to sliding fee schedules is to keep the fee above your costs and above the current Medicare payment for the service. Some practices have client bill relationships.  This is where they are actually allowing the referring physician to bill for their services.  This is typically the case in areas where there is a very competitive environment.  There are numerous Dermatopathology practices that use client billing arrangements. This is also practiced by many large and regional labs.  The overall value and ethics of this practice are quite debatable and I am not a supporter of such practices as it devalues the effort of pathologists....

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The Basics of Auditing Your Pathology Billing, Part 3

Posted by on Jan 5, 2005 in Latest News | Comments Off on The Basics of Auditing Your Pathology Billing, Part 3

This article will cover auditing your pathology revenue generation strategy, which includes Part A contracts, managed care contracting and marketing. The first item reviewed when auditing revenue generation from a typical pathology practice is the group’s Part A plan(s). Most hospital based practices have a Part A contract. The wording in this contract can greatly affect the practice’s revenue. For example, if the contract has punitive managed care terminology, this can suppress revenue generation opportunities. Usually the wording is as such: “group must maintain contracts with all the managed care plans in which the hospital or health system participates.” This one clause can be very destructive. Remember, if the managed care entities know you are forced to sign with them their rates will reflect your loss of leverage. There are effective ways to negotiate around this clause. The next area we review when auditing a practice’s revenue generation is a complete review of all managed care plans. There are numerous pathology practices that cannot even find their managed care contracts and furthermore have never attempted to re-negotiate these contracts. This often leads to lost revenue dollars. We have seen those losses as high as $100,000 or more on some occasions. When performing a managed care audit it is important to review the actual contracts, get actual fee schedules from each plan, build a matrix of these plans and payments and then audit against actual patient explanation of benefit forms (EOBs). Often you will find that there have been higher paying plans assigned to lower paying plans via a third party administrator (TPA) which leads to fewer dollars for the practice. We have numerous testimonials from practices that have gained significant income by reviewing, re-negotiating and re-aligning their managed care contracts. Sometimes being non-participating (non-par) with a managed care company may be the best choice for a practice. Finally when you audit a practice’s revenue generation you must consider the group’s marketing efforts. Many pathology practices do not have a focused marketing arm and only have the efforts of their hospital or health system to rely upon. Unfortunately, the hospital’s marketing plan is usually not in the best interest of the pathology group. There are numerous practices that have strong, aggressive marketing plans and personnel going after the outreach market. Furthermore, the number of companies prospecting for outreach anatomic pathology tissues seems to be ever expanding. This outreach market is only going to grow as the population ages. It is important not to over look the marketing efforts of the practice. Each practice should have a monthly referring physician report that details not only the referring physician volume but the variance for the month, the charge dollars for the month and the collected dollars tied back to the month billed by specific insurance plan. This report should also note the collection percentage for each referring practice and have a charge summary listed by CPT for a 12 month period. With this type of data you can start understanding where your outreach revenue is generated and who is responsible. In summary, these three areas are the most important when a practice looks at their revenue and how it is generated. Failure to keep track of and maintain these points can lead to a weakening of the practice. Usually this is seen over a period of time as the practice starts to lose monthly revenue. Finally, the practice reaches a point where their volume of work is increasing yet their actual revenue is decreasing. At this point they usually contact...

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