Posts made in 2016

Best practices for approaching payer audits

Posted by on Nov 3, 2016 in Latest News | Comments Off on Best practices for approaching payer audits

Best practices for approaching payer audits

As we continue to see an increasing number of payer audits in the pathology world, we wanted to take the time to walk you through some best practices and helpful tips for navigating these audits and protecting your revenue. It’s important to note that these audits will not be limited strictly to Medicare. Many managed care organizations have identified this as potential cost savings and now have their own internal audit teams or have hired third party auditors to validate your charges. Sometimes, these requests may not be directly addressed as an audit and may instead come in another form. It is imperative that you or your biller are on the lookout for these types of communication (or denials). Some auditors are finding 100% error rates – and may go back years to reprocess and take back payments already made to you. You must be vigilant in understanding your contract and the payer’s limitations on takebacks. We’ve seen clients successfully win money back because, under their contract, the payer could only recoup back “x” number of months or years. Unfortunately, many billers are still appealing these incorrectly because they are not communicating these denials and getting the coding department or doctors involved to write these appeals! Several of our groups that bill stains are having issues with limitations of units, medical necessity denials and back end audits.  The billers are often not staffed well enough to have a successful appeal process, which many of these carriers are banking on to begin with! These payers are looking for signed requisitions for IHC/special stains/molecular orders and/or documentation of medical necessity. Action steps for appeals: Include in the pathology report the trigger words:  “ X was ordered because…”. The auditors are most likely not pathologists, they usually just look for trigger words. When an audit request is received, it’s not enough to just send the final reports. Also, include an additional signed attestation by the pathologists that they ordered such and such stains/flow/ihc/molecular. Include a copy of relevant medical chart notes that makes it clear why the pathology specimen was ordered in the first place, i.e. surgeon’s note saying a colectomy was indicated due to presence of cancer or obstruction....

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Navigating MUEs

Posted by on Nov 3, 2016 in Latest News | Comments Off on Navigating MUEs

As with most CMS initiatives, it can be difficult to keep pace with the constantly evolving list of medically unlikely edits, especially when considering CMS and other carriers reserve the right to maintain a list of unpublished MUEs that providers and their billers likely won’t know about until they receive a denial. We were first gifted with these edits when CMS implemented an unpublished MUE list in 2007 with hopes of reducing the error rate of paid claims. Fortunately, the agency decided to begin publicly publishing most MUEs in October 2008, and now updates the list quarterly. In an attempt to highlight the constantly evolving nature of MUEs, we’ve identified changes to the maximum number of allowed units for some of the most popular pathology codes that occurred between the list published by CMS in July 2015 and the most recent one released in October 2016. It’s worth reiterating that CMS and other carriers reserve the right to create unpublished MUEs, which means CMS’s published list is really more of a national guideline than a hard and fast rule. However, an MUEs existence doesn’t prevent you from appealing to potentially receive full payment for all services provided. We work closely with our clients and their billers to make sure billers are appealing MUE denials and that our clients are getting paid on those appeals. But just because a denial is appealed doesn’t necessarily mean you’re going to get paid, especially if the physician’s documentation does not clearly substantiate the necessity of the number of units performed. We have encountered some billers who just want to just slap on a 59 modifier to override the edit, but we’re finding more and more that these MUE edits are often not overridden with a 59 edit. You must support those numbers with sufficient documentation if they exceed the limit. We’ve also seen billers who change the number of units to get around an MUE. Their argument is that the carrier will deny 100 percent of the charges otherwise, so they attempt to get paid on the maximum number of allowed units rather than none. That’s a major red flag in terms of compliance that could create headaches down the road later if you’re audited. While we know many billers don’t want to dedicate the time and resources necessary for an appeal, they need to understand they must bill only what was performed. And if the carrier denies it, they have to go through the appeal process. It’s best to get a handle on that process now if you haven’t already so that you’re not left scrambling down the...

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Want to avoid Medicare penalties under MACRA?

Posted by on Nov 3, 2016 in Latest News | Comments Off on Want to avoid Medicare penalties under MACRA?

Want to avoid Medicare penalties under MACRA?

Sure you do. And we can help. Unless you’ve been living under a rock (or avoiding revenue issues like the plague) chances are you’ve heard the Centers for Medicare and Medicaid Services released the Medicare CHIP and Reauthorization Act (MACRA) Final Rule upon the masses in mid-October. But what does that really mean in terms of how your practice’s Medicare Part B revenue stands to be impacted? We’ve covered seemingly every aspect of MACRA and the Merit-based Incentive Payment System since its passage in 2015 and numerous iterations along the way. And we’ve broken down the system’s various components at length, including taking looks at the varying reporting obligations specialty clinicians face as opposed to their primary care counterparts. This paper, conversely, is intended to provide a brief overview of the action steps most pathologists can take to avoid a penalty to their 2019 Medicare reimbursements based on their MIPS performance next year. MORE: Read our breakdown of the major changes put forth in the final rule. Understand that this won’t answer all your questions if you’re just jumping into the game. But rest assured, we’ve done the research and have answers to nearly any scenario you can think of. Give us a call at 517-486-4262 or email amitchell@vachettepathology.com and we’ll be happy to look into your unique situation. Is there a way I can avoid MIPS? Do you or your group receive less than $30,000 in Medicare Part B payments and see fewer than 100 Medicare patients each year? Are you participating in an Advanced Alternative Payment Model (APM)? Are you a first time Medicare enrollee? Unless you answered “yes” to any of these questions, then you’re most likely stuck going along for the ride. What qualifies an APM as “advanced”? CMS has identified a handful of APMs that use certified EHR technology, feature payments tied to quality metrics similar to those measured by MIPS and require participants to bear some financial risk for reimbursement. In order to avoid MIPS reporting, a clinicians must receive at least 25 percent of their Medicare Part B payments through an advanced APM or see at least 20 percent of their Medicare patients through the model. Those who meet this requirement during the 2017 performance year will automatically receive a 5 percent lump sum incentive payment in 2019. Eventually, participants under this track will also receive a higher annual fee schedule increase. Below is a list of APMs that will qualify for the 2017 performance year: Track 2 and Track 3 Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) Pioneer ACOs NextGen ACOs Oncology Care Model two-sided risk arrangements Comprehensive Primary Care Plus Comprehensive ESRD Care What if I participate in an APM that’s not on this list? If you participate in an APM that’s not on the advanced list, or if you don’t receive enough Medicare payments through the model to meet the participant threshold (noted above), you will be required to report under MIPS, but will likely have a reduced reporting burden. Also, CMS expects to add more APMs to the advanced list each year, so there’s a good chance your model might receive the designation in future years. We’ll be happy to let you know what your requirements for 2017 are if you feel this situation applies to you. OK, I can’t get out of MIPS. Now show me the path of least resistance. If you dread performance reporting, you’ll be happy to know CMS has set an extremely low bar to successfully participate in MIPS during its initial year (which, remember, affects your 2019 Medicare payments because...

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MACRA Final Rule should ease providers’ fears for now

Posted by on Oct 17, 2016 in Latest News | Comments Off on MACRA Final Rule should ease providers’ fears for now

MACRA Final Rule should ease providers’ fears for now

By: Alex Mitchell, Practice Value and News Coordinator At long last, the Medicare CHIP and Reauthorization Act (MACRA) Final Rule has been released upon us, and lo and behold, the sky has not fallen. Our initial analysis shows that all the hand-wringing and apocalyptic proclamations were a bit overstated given that we now know providers who are currently engaged in some form of quality reporting will be able to easily avoid penalties to their Medicare reimbursements for the foreseeable future without being burdened with new reporting requirements. Quick Hits: The “Cost” category of the Merit-Based Incentive Payment System (MIPS) will not have an impact on a clinician’s MIPS score for the 2017 performance year. Pathways offering clinicians the opportunity to avoid Medicare penalties altogether in 2019 by reporting limited or full data sets during an abbreviated window in 2017 were finalized. The low-volume threshold at which clinicians are required to participate under MACRA was raised from $10,000 in annual Part B payments to $30,000 or 100 Medicare patients. More alternative payment models (APMs) are being reviewed by CMS in hopes of expanding the pool of “advanced” APMs that exempt clinicians from MIPS reporting. Perhaps the most important change CMS announced was its decision to finalize a proposal to offer multiple pathways that will allow providers to choose their own reporting pace and level of participation during the 2017 reporting year. Other changes from the proposed rule include the elimination of the “cost” category for the 2017 reporting year, the establishment of a higher threshold for low-volume providers to qualify for participation, and an expansion of what qualifies as an “advanced” alternative payment model under MACRA. Let’s breakdown the major changes: 2017 “Transitional” Year: Before we dig into the minutiae of the change put forth in the final rule, providers should be sure they fully understand just how low CMS has set the bar for satisfactory participation during MACRA’s inaugural year. Clinicians who will be fulfilling their MACRA requirements by participating in the Merit-Based Incentive Payment System will only need to report one quality measurement, one practice improvement activity or fulfill the requirements of the Advancing Care Information category in order to completely avoid a negative adjustment of up to 4 percent of their Medicare Part B reimbursements in 2019. This massive change from the proposed rule that was released in April partially came about as a result of the thousands of comments CMS received, many of which pointed out that a significant portion of MIPS-eligible providers wouldn’t be ready to fully participate next year. That being said, the minimal reporting requirement should only be considered by providers who have been ignoring the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM) and Electronic Hospital Record Meaningful Use (EHR MU) reporting to this point. CMS appears to have offered this route as a concession for these latecomers in hopes that they’ll become full participants in later years. The vast majority of providers who have already been engaged in some form of quality or cost reporting should instead consider either reporting during a reduced 90-day window in order to be eligible for a small Medicare boost in 2019, or attempt to report for the full 2017 calendar year in hopes of receiving a full 4 percent bonus (and possibly more if they display exceptional performance). Deciding the correct route for your practice will require you to take a hard look at your past quality reporting to determine at what level you can comfortably succeed. Another new development is CMS’s announcement that the 2018 performance year will also be a considered a “transitional”...

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How pathologists can survive MIPS in 2017

Posted by on Sep 19, 2016 in Latest News | Comments Off on How pathologists can survive MIPS in 2017

How pathologists can survive MIPS in 2017

Is your practice still scrambling to get a handle on the ins and outs of the Merit-Based Incentive Payment System before it goes into effect Jan. 1? Well, take solace in knowing you’re not alone. In its current iteration, the proposed MIPS rule laid as part of the Medicare Access and CHIP Reauthorization Act (MACRA) was, simply put, not designed with pathology in mind. Under MACRA, physicians have the option to avoid MIPS participation by participating in various alternative payment models that the Centers for Medicare and Medicaid Services deems to be “advanced.” The bad news: Very few APMs currently qualify for participation and CMS won’t start accepting proposals for specialty-focused Physician-focused Payment Models (PFPM) until early 2017. This means eligible pathologists will be forced to at least partially participate in MIPS during the 2017 performance year, or risk facing future penalties to their Medicare reimbursements. Fortunately, the good folks at the College of American Pathologists are working to develop a pathology-focused alternative payment model that they hope will receive approval next year from CMS. Vachette has stayed on top of MIPS news throughout its development and has spent considerable time researching what the payment system will mean for pathologists, both in the short- and long-term. Here’s a breakdown of what you need to know: Performance Categories By now, you’ve likely read or heard at least some information on the four categories that will be measured to compile your total MIPS score. But here’s what you may not know: Pathologists will likely only be scored in two of the four categories, and possibly only one if you’re an independent lab. For a quick refresher, let’s run through the categories briefly and note how each ties to an existing quality measurement program.   Quality: At 50 percent of your total MIPS score, this category is the most heavily weighted among the four. It will act as the successor to the Physician Quality Reporting System, which is currently in its final performance year (PQRS penalties, meanwhile, will be levied through 2018). At the behest of CAP, CMS has stated it will allow pathologists use CAP’s eight quality reporting measures for 2017, however, there is no guarantee that will be the case in subsequent years. Those quality reporting categories include: Breast Cancer Resection Pathology Reporting Colorectal Cancer Resection Pathology Reporting Barrett’s Esophagus Pathology Reporting Radical Prostatectomy Pathology Reporting Evaluation of HER2 for Breast Cancer Patients Lung Cancer Reporting (biopsy/cytology specimens) Lung Cancer Reporting (resection specimens) Melanoma Reporting *IMPORTANT NOTE FOR INDEPENDENT LABS: The proposed rule appears to exclude independent labs from reporting quality metrics, however, CAP is still seeking clarification from CMS at this time. Under the proposed rule, eligible clinicians (EC) or groups that are exempt from a reporting category will have that category’s weight redistributed to the remaining categories. Resource Use: Weighted at 10 percent of an EC’s total MIPS score, resource use will replace the value-based payment modifier. As with VBM, pathologists will not face reporting requirements for resource use, since CMS calculates the category based on claims. Again, this category will be reweighted to zero and redistributed to remaining reporting categories. Advancing Care Information: This replacement for the existing EHR Meaningful Use program is slated to be worth 25 percent of an EC’s total MIPS score. But, (stop me if this is becoming a reoccurring theme) pathologists also won’t be measured for ACI due to there being a lack of applicable measures. Clinical Practice Improvement: Finally, we have a category that does apply for pathologists, albeit in a limited manner as currently presented. Weighted at 15 percent of...

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