Latest News

Time is running out for MIPS Improvement Activities!

Posted by on Sep 20, 2017 in Latest News | Comments Off on Time is running out for MIPS Improvement Activities!

Time is running out for MIPS Improvement Activities!

If you’re an individual or group planning to participate in the new Improvement Activities (IA) category of MIPS, you should be aware that you must begin engaging in your chosen activities by no later than Oct. 2 in order to complete the 90 days of participation requirement in 2017. While non-patient facing (NPF) and small physician groups face a lower reporting burden than regular participants, the IA category still counts for 15 percent of your overall MIPS score, regardless of the number of activities you’re required to complete. As a refresher, activities are weighted as either high or medium depending on their administrative burden. A patient-facing group must complete some combination of the following: two high-weighted, four medium-weighted, or one high and two medium-weighted. Meanwhile, NPF  physicians and groups of 15 or fewer providers must only complete either one high-weighted or two medium-weighted activities to earn the full 40 points available for the category. If you’re unsure whether or not your group qualifies for special status under MIPS, you can check by entering your NPI at qpp.cms.gov. CMS has approved a list of 93 activities for 2017. If you’re unsure which activities would work best for your group, take time to review the whole list to check whether you’re already engaging in an improvement activity. Vachette has also assisted numerous clients through this process and is available to make recommendations on activities that would best suit your practice. While you won’t be required to report anything to CMS during the 90 days you’re completing the activity, you will be expected to sign an attestation form stating you completed the activity when CMS opens the attestation portal sometime in early 2018. This form will simply require you to complete a survey with questions pertaining to your chosen activity. You’re not required to submit documentation proving you completed your activities, however, you should still be documenting completion of the activity in the rare event CMS elects to audit your MIPS performance. One activity that we’ve recommended for several pathology clients is a high-weighted activity titled “24/7 Access to the MIPS Eligible Clinician With Access to Patient Records.” Since the vast majority of pathologists already have someone from their group available 24/7, this is a relatively simple choice. To document this activity, groups should be maintaining a shift log showing who from the group was available on what days during the extended evening and weekend hours. Additionally, patient-care activities performed during these hours should also be documented. This could include items such as a blood smear interpretation signed out of your EMR, or a surgical pathology report that was signed electronically during normal business hours a day or two after the “after hours” event, but includes documentation of an after-hours frozen section evaluation that was part of the case. Regardless of which activities you choose, now is the time to get moving if you haven’t already. If your group is just looking to avoid the 2019 MIPS penalty, completing just a single improvement activity this year will help you achieve that goal. Don’t wait until it’s too late to...

read more

Avoiding scrutiny under the new CMS audit process

Posted by on Sep 5, 2017 in Latest News | Comments Off on Avoiding scrutiny under the new CMS audit process

Avoiding scrutiny under the new CMS audit process

With CMS recently announcing the agency is directing its Medicare Administrative Contractors to focus their audits and claim reviews on providers with consistently high error rates, it’s important to understand specifically what shortcomings could put your claims process under the microscope. CMS has said the goal of this new initiative, dubbed the Targeted Probe and Educate Pilot, is to prevent fraud, avoid unnecessary payments and to be less of a burden on providers whose billing operations are running smoothly. Select MACs will be asked to choose claims for services that carry a significant financial burden for Medicare, in addition to those that produce consistently high error rates. The good news is that unlike the old review system, which included all providers for a designated service during the initial round, providers who are already submitting claims with low error rates will be exempted from the review process. Unfortunately, while this new process will reward compliant health systems with less oversight, those who are found to be consistently falling short of CMS’s standard will need to show substantial improvement between reviews to avoid penalties. Those who are determined to still have an undesirable error rate after three rounds of review could face actions such as referral to a recovery auditor or 100 percent pre-pay review. Providers must display an ability to reduce their claims error rate between rounds of review in order to be removed from the cycle. So what does this mean for the average group? For starters, it’s more important to ensure your billing staff is informed of this change and is working with you to minimize coding errors. Even small mistakes could put you under the crosshairs of the new process. In one recent example, our audit team reviewed a caseload where  we found 2 percent of cases reviewed had a coding error that caused prostate TURP to be billed as G0416 to Medicare after the biller’s system mistakenly updated 88305 to G0416! Repeated mistakes like these are what MACs will be looking to identify. If you have any concerns about your claims process, now may be the time to consider preemptively bringing in a third-party auditor to review your work before the government comes calling. Vachette has worked with hundreds of clients throughout the nation and has the ability and expertise to identify and correct problem areas in your billing...

read more

Lab prior-authorization programs continuing to evolve

Posted by on Aug 7, 2017 in Latest News | Comments Off on Lab prior-authorization programs continuing to evolve

Lab prior-authorization programs continuing to evolve

With United Healthcare set to unveil a national prior-authorization process for genetic and molecular testing for fully insured members on Oct. 1, most major health plans are now utilizing some form of a laboratory benefits management (LBM) program in various parts of the country. But what’s driving this trend? For starters, many of these insurers are finally admitting they lack the necessary expertise in the laboratory field to determine medical necessity and properly rein in potential fraud and abuse within the industry. That, coupled with the potential cost savings these plans will realize by driving business to preferred, in-network providers, has led to a relative explosion of these programs in recent years. Currently, there are only a handful major LBM programs throughout the country, with more likely to be introduced in the coming years. Below is a quick overview of each. Beacon Laboratory Benefit Solutions (LBS) First implemented as a Florida pilot in Oct. 2014. Under the program, physicians serving UHC’s commercial patients in Florida must notify UHC when ordering any of 81 clinical laboratory tests, including ANA, C. difficile toxins, Pap test (with or without HPV), biopsies, and thyroid panel, among others. Pre-authorization is also required for some, but not all of these tests. The program does not allow use of out-of-network laboratories. Allows providers to be either “participating” or “preferred”. Preferred providers are contracted at a lower rate than the UHC contracted rate. Front-end physicians must order and pre-authorize the test within 10 days of the DOS and the pathologist must verify the pre-authorization. Payments are denied for any lab tests that don’t meet the Beacon requirements, however, there is no penalty to referring physicians who do not comply with the program. Originally slated to be implemented in Texas on March 1, 2017, however, pushback from various physician groups has delayed that implementation indefinitely. No new date for installing the program has been established, but groups have been informed they will be informed 90 days in advance before it goes into effect. UHC’s pre-authorization program Prior-authorization program for genetic and molecular tests for fully insured commercial members went into effect on June 30. On Oct. 1, UHC will install a national, online prior-authorization program in the outpatient setting. Will require lab name, name of test, name of gene and clinical info. Participants in the Florida Beacon LBS program will be exempt from participating. Aiming to ensure appropriate testing and medical necessity. Avalon Healthcare Currently affects entire lab network for Blue Cross Blue Shield of South Carolina, including hospitals, physician offices and independent labs. Also in effect for BCBS of North Carolina, but only for independent labs. Requires labs who wish to become in-network to contract with Avalon and agree to meet certain quality and data reporting conditions. Avalon assumes financial risk in order to manage all lab spending for the plan. Has created administrative issues by requiring submission of two 835 files, one from the payer and one from Avalon. Many pathologists have had to adjust their billing software to accommodate two files. This has led to an increased manual workload for labs. Full list of impacted codes EviCore Healthcare BCBS, Aetna, Cigna and some others currently participate. Unfortunately, each plan has slightly different policies. Operates both a medical oncology appropriate use and LBM program. Given that EviCore...

read more

What pathologists can expect from the 2018 Medicare Physician Fee Schedule

Posted by on Jul 17, 2017 in Latest News | Comments Off on What pathologists can expect from the 2018 Medicare Physician Fee Schedule

What pathologists can expect from the 2018 Medicare Physician Fee Schedule

After significantly cutting the technical component for a number a key of pathology CPT codes last year, pathologists should be relieved to hear the vast majority of reimbursements levels are expected remain relatively unchanged next year, according to the proposed 2018 Medicare Physician Fee Schedule. The biggest hit will again impact the Global and Technical reimbursements for prostate biopsies (G0416). CMS is proposing to dock the Global rate by 11.5 percent and the Technical component by a whopping 18.7 percent, dropping their totals to $434.40 and $247.61, respectively. This comes as little surprise, as CMS has slashed payment for prostate biopsies throughout the past half-decade. The other most significant cut will be experienced by flow cytometry codes 88185-TC and 88189-26, with the technical side expected to be cut by 18.8 percent to $30.59 and the professional interpretation set to experience a 4.4 percent reduction to $88.54. Bad news aside, pathologists will be happy to hear all components of 88305 will receive a slight boost this year after seeing its technical and global component slashed by 15 percent and 7 percent, respectively, last year when compared to 2016 compensation rates. Professional interpretations for 88305 will jump 1.2 percent to $40.31, while Global and Technical reimbursement will both experience increases of less than 1 percent. Overall, CMS anticipates their proposed 2018 amendments will cut pathologists overall compensation rates by just 1 percent, while independent labs will see a 2 percent reduction. Keep in mind that the conversion factor for 2017 was $35.8887, while the proposed factor for 2018 is 35.9903. The overall update to payments under the PFS based on the proposed 2018 rates would be .31 percent. The update reflects the .5 percent annual increase established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by -.19 percent due to the misvalued code target recapture amount, according to CMS. Check out the chart below for a breakdown of the major proposed changes for several key pathology codes. In the spirit of brevity, code sets expected to see cuts or boosts of less than 1 percent were not listed. CPT Code Service Proposed 2018 Current 2017 Change 88112 – Global Cytopath cell ehance tech $69.82 $68.91 1.3% 88112 – TC Cytopath cell ehance tech $40.31 $39.84 1.2% 88112 – 26 Cytopath cell ehance tech $29.51 $29.07 1.5% 88121 – Global Cytp urine 3-5 probes cmptr $536.26 $553.76 -3.2% 88121 – TC Cytp urine 3-5 probes cmptr $484.07 $501.72 -3.5% 88121 – 26 Cytp urine 3-5 probes cmptr $52.19 $52.04 0.3% 88184 – TC Flowcytometry/ 1st marker $61.18 $61.73 -0.9% 88185 – TC Flowcytometry/ additional marker $30.59 $37.68 -18.8% 88189 – 26 Flowcytometry/ read 16+ $88.54 $92.59 -4.4% 88305- Global Tissue exam by pathologist $70.18 $69.62 0.8% 88305 – TC Tissue exam by pathologist $29.87 $29.79 0.3% 88305 – 26 Tissue exam by pathologist $40.31 $39.84 1.2% 88307 – Global Level V, tissue exam by pathologist $268.49 $269.88 -0.5% 88307 – TC Level V, tissue exam by pathologist $180.67 $181.96 -0.7% 88307 – 26 Level V, tissue exam by pathologist $87.82 $87.93 -0.1% 88309 – Global Tissue exam by pathologist $407.41 $413.80 -1.5% 88309 – TC Tissue exam by pathologist $251.57 $258.40 -2.6% 88309 – 26 Tissue exam by pathologist $155.84 $155.40 0.3% 88312 – Global Special stains group...

read more

6 Highlights of the 2018 MIPS Proposed Rule

Posted by on Jul 13, 2017 in Latest News | Comments Off on 6 Highlights of the 2018 MIPS Proposed Rule

6 Highlights of the 2018 MIPS Proposed Rule

While many clinicians are still working to get a handle on the requirements for the Merit-based Incentive Payment System, they also need to keep an eye on how the program is expected to evolve next year now that CMS has released its 2018 Quality Payment Program Proposed Rule. However, those fearing the bar for penalty avoidance would be raised to unreasonable heights should breathe easy knowing CMS won’t require much more from you than what they asked for in 2017. With that in mind, here are six of the most significant changes:   1)    Significant increase of the low-volume thresholds CMS has proposed to raise the low-volume MIPS exemption thresholds to $90,000 in annual Medicare payments or services to 200 or fewer Medicare beneficiaries, a significant increase from the $30,000 or 100 patient thresholds for 2017. Falling below either one of these thresholds as an individual clinician will exempt you from participation, which means those who were barely over this year’s mark will most likely be exempt from the program next year. Keep in mind, however, that the increased threshold is also applied at the group level if your group elects to report collectively.   2)    No requirements for the “Cost” category While participants had originally been told to anticipate the introduction of a “Cost” category based on the old value modifier in 2018, CMS is now proposing to again give no weight to the fourth MIPS category next year. That being said, the agency is still soliciting feedback on whether Cost should be weighted at 10 percent of the total MIPS score for 2018, given that CMS still intends to count it as 30 percent of a participant’s score in 2019. Regardless, CMS says it intends to track Cost progress in 2018 based on Medicare Spending per Beneficiary and total per capita cost measures. They’re also working to develop a handful of episode-based cost measures.   3)    Slight threshold increase for penalty avoidance Clinicians who were happy with the extremely low bar set by CMS this year to avoid a Medicare penalty in the 2019 payment year should find relief in learning they won’t be asked to do much more next year to avoid a 2020 penalty. While the 2017 performance threshold of 3 (the total MIPS score required to receive a neutral adjustment) was able to be achieved by essentially submitting any quality data or completing at least one improvement activity, the 2018 threshold will be raised to just 15 points. This can be achieved in a variety of ways, including by submitting complete data for just two quality measurements or completing the full requirements of the improvement activities category. Non-patient facing clinicians, hospital-based groups and groups consisting of 15 or fewer members will still only be required to complete either one high-weighted or two medium-weighted activities to get the full score.   4)   Automatic bonuses for small and rural practices Given the reporting hurdles faced by small (15 clinicians or fewer) and rural practices, CMS is proposing to award an automatic five points to these clinicians scores next year. This is likely to be locked in for small practices, however, CMS is still seeking comment on whether rural practices should receive the same benefit.   5)    New facility-based scoring mechanism No concessions for facility-based clinicians was...

read more

How do you view the pathology recruitment market? (Survey)

Posted by on Jun 26, 2017 in Latest News | Comments Off on How do you view the pathology recruitment market? (Survey)

How do you view the pathology recruitment market? (Survey)

How do you view the current state of the pathology recruitment market? What kind of future do you see for the practice of pathology in the Unites States moving forward? We’re seeking pathologists to help answer these questions and more as part of a survey that will be discussed during a group panel at the upcoming Association of Pathology Chairs Annual Meeting, July 25-28 at in Washington, D.C. Vachette President Mick Raich will participate in the panel, which will seek to assess the current state of pathology in the U.S. by discussing current reimbursement levels, workload and more. The full survey can be viewed here. There are a total of 12 questions, and any answers you choose to provide will remain completely anonymous. Your participation is greatly...

read more

Salary Study Update: Michigan Pathologists in 2017

Posted by on Jun 13, 2017 in Latest News | Comments Off on Salary Study Update: Michigan Pathologists in 2017

Salary Study Update: Michigan Pathologists in 2017

Earlier this year, we published a white paper that included breakouts in all of the major financial categories for pathologists across the nation based on our client data. We’ve since decided to crunch the numbers a bit further to provide an idea of what the average salary is for a pathologist in Michigan. MORE: Click here to download our pathology compensation study. Vachette manages more than $43 million in annual revenue generated by 82 pathologists throughout the state of Michigan. The average salary that we see in Michigan based on our client data is $531,000 per pathologist. However, you should understand this average was drawn from several different groups operating under varying fee schedules, which may partly explain why you fall below that total. If you are curious as to what Vachette can do to specifically increase your revenue, perhaps now is the time for us to talk. With PAMA cuts expected to reduce current CMS compensation rates by as much as 10 percent in each of the next three years (and that’s not including potential Merit-based Incentive Payment System penalties that will grow in the coming years), ensuring that your revenue cycle management is up to snuff is more important than ever. By auditing processes quarterly and keeping up on industry changes, we keep our clients ahead of the game financially, all while helping them avoid breakdowns in their billing processes. We have been working with hospitals, laboratories, and hospital-based groups for more than 15 years and would love to serve you as well. If you’re interested in learning more about how Vachette can help you generate more revenue, or simply want more info on our audit process, feel free to contact us directly at...

read more

Missed appeals, MUE denials and more in Vachette’s latest audit roundup

Posted by on May 31, 2017 in Latest News | Comments Off on Missed appeals, MUE denials and more in Vachette’s latest audit roundup

Missed appeals, MUE denials and more in Vachette’s latest audit roundup

As we’ve continued to add new clients in 2017, Vachette’s audit team has been hard at work uncovering and correcting a host of billing and compliance issues in an effort to put missing revenue back in our group’s pockets. As always, failure to properly appeal various denials has continued to be an issue we see with alarming regularity. We’ve also identified a host of issues tied to outdated fee schedules, missing contracts and other often overlooked problems that prevent groups from maximizing their revenue. If you’re interested in learning more about any of our findings or our audit process in general, feel free to contact us directly at 517-486-4262. For updates on our latest finds, follow us on Facebook, Twitter and LinkedIn or visit our website, www.vachettepathology.com. Below are Vachette’s top auditing findings so far in 2017:   Ignoring too many appeals — January 4, 2017 Too often, billers let appeals slip between the cracks and voluntarily write off a large source of potential revenue in the process. Case in point: This week, our team discovered that 16 percent of the cases we reviewed for our client during a billing audit were lacking appeals. Even if you assume only a third of the appeals would be successful, we still projected our client could have lost $775,000 in revenue for the year if the error rate held constant!   Maximizing your fee schedule — January 11, 2017 We cannot stress enough how important it is to ensure your fee schedule is set at a level that maximizes the reimbursements you receive from various insurance carriers. During a recent billing audit, we noticed our client’s fee schedule for 85060 was just $40, a figure that was significantly lower than the amount four different carriers were willing to pay for the service! This is lost revenue!   Missing documentation leads to MUE denials — January 18, 2017 Ensuring your reports are properly documented is crucial, especially as MUE denials become increasingly prevalent. We recently had a client whose biller submitted a claim to Medicare with eight 88361 units and filed an appeal in the report since the MUE for the code is six. Although Medicare acknowledged eight stains were performed, they still denied the claim because the report lacked documentation stating 88361 is computer assisted. We’ve since helped our client install a process to ensure the proper documentation for these cases will be included on all future cases moving forward. Missing codes lead to denials — January 25, 2017 As insurers become increasingly diligent with its denials, groups must be more cautious than ever when it comes to ensuring claims are properly coded. During a recent billing audit, we discovered 4 percent of the cases reviewed showed Medicaid secondary insurance was denied because the taxonomy code in box 33B on the claim form was missing, causing the claims to be denied as NPI not matched. Unfortunately, our client’s biller adjusted the balance off the system and did not refile when the issue was corrected, which left potential revenue on the table   Failure to appeal costs client big time — January 31, 2017 $227,000 — That’s the amount we projected our client could have lost over the course of a year after we discovered their biller was not submitting appeals on cases...

read more

Check your MIPS status online with new CMS tool

Posted by on May 8, 2017 in Latest News | Comments Off on Check your MIPS status online with new CMS tool

Check your MIPS status online with new CMS tool

While most clinicians should have received their Merit-based Incentive Payment System (MIPS) eligibility letters by now, CMS has also recently provided groups a way to check online whether or not they are required to participate in the new quality reporting program. Individuals can check whether they fall below the Medicare volume threshold ($30,000 or less in Medicare payments or seeing 100 or fewer Medicare patients) or qualify for another exemption by entering their NPI here: https://qpp.cms.gov/learn/eligibility. It’s important to note that if an individual doctor is told they don’t meet the thresholds to be forced to participate as an individual, they don’t have to report with clinicians in their group who do have to participate unless they elect to report as a group. In that case, even doctors who don’t meet the volume thresholds would be required to participate with their group. With that in mind, some of groups may decide it’s best to report as individuals instead of as a group if they have multiple members who don’t have to participate and would prefer to avoid being affected by bonuses or penalties. CMS is basing its participation determinations on 12 months of data ranging from Sept. 1, 2015 to Aug. 31, 2016. Later this year, another assessment will be run based on data between Sept. 1, 2016 and Aug. 31, 2017. That means that even if someone is told right now that they have to participate, that may change later this year when later data is reassessed if their Medicare volumes went down between the two periods. Just as a reminder, clinicians enrolled in Medicare for the first time in 2017 are also exempt for this...

read more

Looking for a registry to assist with 2017 MIPS? Check out the full CMS list

Posted by on Apr 20, 2017 in Latest News | Comments Off on Looking for a registry to assist with 2017 MIPS? Check out the full CMS list

Looking for a registry to assist with 2017 MIPS? Check out the full CMS list

With the inaugural reporting period for the Merit-based Incentive Payment System now underway, physicians should be preparing to report their quality metrics and practice improvement activities if they’re not participating in an Advanced Alternative Payment Model that exempts them from MIPS. While many individual physicians and groups were able to survive the Physician Quality Reporting System through claims-based reporting, the expected elimination of that reporting method after 2017 means groups should be considering their options to get on board with a registry that can assist with MIPS reporting. Late last week, CMS released its list of approved registries for 2017. The full list can be viewed here. CMS-approved registries and clinical data registries collect quality data from a clinician or group practice and submit it to CMS on behalf of MIPS participants. Unlike claims-based reporting, which essentially sets a reported measure in stone once an applicable claim is submitted to CMS, registries can provide ongoing feedback on your reporting before it’s finalized to help ensure you’ve reported to the best of your ability, as opposed to waiting for CMS to provide feedback on your work more than a year after it’s been submitted. One of the most noteworthy new additions for Pathologists is the Pathology Quality Registry offered by the College of American Pathologists. While the registry is not expected to go live until it can be unveiled at the CAP annual meeting this fall, CAP officials have said they plan to offer an additional eight pathology-specific quality measures in addition to the eight that have carried over from PQRS (although they’ve yet to reveal what those measures will be). This means that groups who previously had little hope of receiving a bonus due to a lack of applicable measures may now have more options available to them. Typically, we’ve seen these registries cost groups about $300-$400 per reporting physician. However, we strongly suggest you attempt to negotiate a better rate if you’re part of a large group. Feel free to contact Vachette if you’ll be utilizing a registry for the first time this year. We’ve worked with several registries on behalf of our clients and would be happy to provide guidance to help you find the partner that can best help your group maximize its MIPS scoring potential. While there are numerous registry options available, you’ll want to be sure you only consider registries that support the quality measure groups or individual measures that are applicable to your practice. Keep in mind that Vachette also offers additional guidance that can help you or your practice work through the numerous changes to value metrics. For the cost of a few specimens per month, we will ensure you do not lose any money during the transition from PQRS to MIPS. Contact our office at 517-486-4262 today so we can help you get...

read more