Posts made in 2011

Provider Information Revalidation – It’s Mandatory!

Posted by on Dec 16, 2011 in Latest News | Comments Off on Provider Information Revalidation – It’s Mandatory!

Have you received noticed from your MAC (Medicare Administrative Contractor) that it’s time for you to revalidate your enrollment information? If you enrolled with CMS prior to March 25, 2011, you will be receiving notification soon! According to Section 6401(a) of the Affordable Care Act, all providers and suppliers must revalidate their enrollment information BUT only after notification from the MAC to do so. This process is ongoing and is expected to be completed by March 2013. The revalidation may be completed online through the Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the 855 form.  Supporting documentation is required. If your billing agency normally handles your credentialing process, they will be well-equipped to handle this update.  The website for revalidation is  If this is something to be handled internally, be on the lookout for the request from your MAC! Note that failure to complete this process may result in deactivation of your Medicare billing privileges! Source:...

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In-Office Labs with CAP Accreditation… A Juxtaposition?

Posted by on Dec 13, 2011 in Latest News | Comments Off on In-Office Labs with CAP Accreditation… A Juxtaposition?

More in-office labs are getting CAP accreditation even though the College of American Pathologists is vigorously lobbying Congress to exclude anatomic pathology from the in-office ancillary services exception to the Stark rules that prohibit self-referral. CAP states that when physicians order on the basis of financial interest, there is enormous potential for over-utilization of testing.  Ironically though, more and more labs are getting CAP accreditation. CAP clarifies its position on In-Office labs in October’s issue of Laboratory Economics… In regard to in-office laboratory business arrangements, the CAP’s fundamental concern is that under the Stark in-office ancillary services self-referral exception, the incentive—regardless of accreditation—is to order and provide more testing services than are necessary, leading to overutilization of services and higher costs to the system. The incentives in these arrangements are misaligned, as is made clear by Congress’s current efforts to move away from these types of payment incentives. The CAP accreditation process focuses on ensuring that ever lab we accredit meets the highest possible standards for operation under the law. Through the process, we verify what testing and services are provided, and ensure that they comply with CLIA. However, the accreditation process does not include scrutinizing or collecting information on a lab’s business arrangements. Due to the requirement that CAP-accredited labs provide like-teams to participate in the accreditation of other labs, it is rare for an in-office lab to quality for CAP accreditation. However, it can happen if the lab meets all of CAP’s requirements, or if CAP review is requested by CMS, which does happen from time to...

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Local Coverage Determination: KY and OH

Posted by on Nov 17, 2011 in Latest News | Comments Off on Local Coverage Determination: KY and OH

The recent change of Medicare Part B contractor from Palmetto to Cigna Government Services that took place in July 2011 also brought about changes to the LCD for IHC’s and Flows for Ohio and Kentucky. An LCD, Local Coverage Determination, is the guideline that is required by CMS for fiscal intermediaries, MAC contractors, and carriers to issue to direct providers how to submit claims for certain services. LCDs also designate diagnosis codes needed to justify medical necessity for services, establish billing guidelines, and include limits on frequency and patient eligibility. Below are the changes for Immunohistochemistry and Flow Cytometry for CGS that pathologists need to be aware of moving forward. Your billing service should also be aware of the new policies. LCD L31873 for code 88342 Immunohistochemistry, each antibody This LCD includes a list of diagnosis codes that CGS feels supports the medical necessity for reimbursement for this service. The list is rather extensive and pertains to many conditions across the organ systems but excludes many common signs & symptoms often associated with pathology billing such as nausea, vomiting, diarrhea, and abdominal pain. The LCD also imposes limits on the number of payable units per specimen. CGS states that it would be unusual for more than ten (10) units to be medically necessary for one sample of tissue. Units reported above this threshold should be supported in the pathology report. LCD L31870 for codes 88182 – 88189 Flow Cytometry The LCD for flow Cytometry also includes a list of diagnosis codes felt to support medical necessity for reimbursement. The list mostly includes neoplasms, conditions of the endocrine, nutritional and metabolic systems, and diseases of the blood and blood-forming...

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The Retroactive Cheeseburger Tax

Posted by on Nov 8, 2011 in Latest News | Comments Off on The Retroactive Cheeseburger Tax

Medi-Cal the California Medicaid program is proposing cutting payments 10% and is also looking back retroactively to June 1, 2011 for recoupments. This means that if you provided treatment to patients between June 1, 2011 and now, Medi-Cal will take back 10% of those payments.  In simple terms it is like going to a restaurant for a cheeseburger today only to be told you owe an extra $.40 for the burger you bought back in June as the price for the past eaten cheeseburger has now been increased. Of course there will be some legal actions and the subsequent fight but what about the principle of the idea.  The Department of Health Care Services, DHCS noted that “there will be no appreciable impact on beneficiary access to providers after these reimbursement reductions.” Really, do you think providers are going to scramble for more Medicaid patients knowing that at any time the state can say “we changed our minds; you now owe us 10% of the payments that we paid you over the past four...

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Cigna Changes Again

Posted by on Jul 19, 2011 in Latest News | Comments Off on Cigna Changes Again

It has come to our attention that major changes are in the works for Cigna providers. Here is a simple list: In several states we have seen Cigna propose a rate that is closer to the Medicare Clinical Fee Schedule versus the Medicare Physician Fee Schedule. This is a huge problem as the clinical fee schedule pays about 50% of the physician fee schedule. The most interesting thing noted here is that they are proposing these rates to PHO’s and stating that this is the current CMS fee schedule. It is, but it’s the wrong fee schedule! Be aware. In another move, Cigna has lowered the filing limit on some contracts from 180 to 90 days. Again this is just another play by the payers to limit payment for...

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