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Biller’s fee schedule oversight a costly one for Southern pathology lab

Posted by on May 19, 2016 in Latest News | Comments Off on Biller’s fee schedule oversight a costly one for Southern pathology lab

Biller’s fee schedule oversight a costly one for Southern pathology lab

Problem: A quarterly audit for an independent Southern pathology lab unveiled the lab received $31.94 less for its global 88305 CPT codes (a microscopic tissue examination to provide diagnosis) than its contracted rate with a large commercial insurance carrier allowed on about 50 percent of the codes reviewed. When contacted about the discrepancy, both the lab’s third-party biller and the carrier said they were unaware of the problem and were unsure as to why it was occurring. Since this particular carrier accounts for roughly 38 percent of the lab’s payer mix, the auditor determined the client could have lost up to $82,000 in 2015 if 50 percent of the lab’s total 88305 volume was underpaid as the audit showed. Process: To confirm the error, our auditor went as far as to locate two different cases that were billed identically (even down to the pre-fix) except for the patient ID numbers. Both were paid different rates, solidifying that there was no discernible reason for the difference. We’re also working to determine how the biller initially followed up on this case since the audit shows they received payment from the insurance carrier for a batch of 88305s and their system automatically accepted the adjustment on the same day. On its face, it looks like the biller was simply accepting what the carrier was paying without question. We are now following up to see if there is any possibility to appeal to reclaim these underpayments. Recommendations: Follow up with your biller the moment you feel revenue isn’t adding up: In this instance, our client said he felt like he was losing $10,000 a month despite doing more work. His gut feeling was correct. Know the appeal limit in your contracts: Sadly, some contracts with carriers stipulate providers have only 180 days to appeal for an underpayment. After that, any money owed to the provider is lost. Performing a regular quarterly audit will help ensure underpayments are identified in time for an appeal to be made. Most importantly: Your billing staff or company MUST actually compare the paid EOB to the amount you are allowed to collect. This can be difficult since many billers have a “managed care tracking module” in their software that is often rendered useless due to constant fee schedule changes. This comparison takes time and money, but in the end, the client makes more money. Who’s watching your revenue like this? Is this happening to your practice and you simply are unaware? Questions about how we can help maximize your practice’s revenue stream? Contact Mick Raich, president of Vachette Pathology and Stark Medical Auditing, at mraich@vachettepathology.com or call us at...

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Trump and Clinton on health care: The status quo vs. an undefined vision

Posted by on May 12, 2016 in Latest News | Comments Off on Trump and Clinton on health care: The status quo vs. an undefined vision

Trump and Clinton on health care: The status quo vs. an undefined vision

By: Alex Mitchell, Director of Information and Content Here we go. With Donald Trump having secured the 2016 Republican Party Presidential nomination after his two remaining primary opponents, Texas Senator Ted Cruz and Ohio Governor John Kasich, suspended their campaigns on the heels of Trump’s dominating win in the Indiana Primary, Trump’s campaign has now switched its focus to preparing for his likely Democratic opponent in the general election, former Secretary of State Hillary Clinton. Clinton needs to secure only a modest number of delegates in the remaining state primaries to ensure the Democratic nomination and avoid a contested convention with Vermont Senator Bernie Sanders. In a past life, I worked as a political reporter for a daily news outlet in Michigan, so I’ve seen my fair share of divisive candidates and issues. I can’t say, however, that I’ve ever seen two candidates as polarizing or as widely despised by opponents as Trump and Clinton. Whether it’s Trump’s at times bombastic rhetoric and status as an outsider to the Republican establishment, or Clinton’s missteps with Benghazi or her private email server during her time as Secretary of State, it’s clear that neither candidate is immune to criticism. While the two differ greatly on a wide variety of issues, their positions on health care reform should be watched closely in the lead up to the November general election. Clinton had made it clear she considers the Affordable Care Act a success that should be expanded on – albeit with a number of adjustments. Trump, on the other hand, has stated he would repeal Obamacare, but only recently has offered concrete details as to what a potential replacement might look like. Trump: With Trump, voters aren’t being sold on a specific health care vision, but are instead being offered a promise of reform many Republicans have called for since 2010: repealing Obamacare. Make no bones about it, Trump has made abolishing the controversial law a focal point of his campaign, going so far as to state on his campaign website that “On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.” Let’s take a look at the other areas of health care reform Trump mentioned in March when his team released a seven-point plan that attempted to give backbone to his health care vision. In the plan, Trump pledged to: Abolish the ACA mandate requiring individuals to purchase health care. Allow individuals to make tax-free contributions to health savings accounts that would accumulate indefinitely and could be passed on to heirs without penalty. Allow individuals to fully deduct health insurance premiums from their tax returns. Modify laws to allow the sale of health insurance across state lines in hopes that increased competition will drive down costs. Convert Medicaid into a block-grant program to allow states to manage Medicaid without federal oversight. Allow protections for those with pre-existing conditions to remain intact. Relax regulations to allow cheaper drugs from overseas to enter the American market and require “price transparency” from all health care providers. Financials: Trump’s plan to repeal and replace Obamacare is estimated to cost $330 billion over a 10 year period when including estimates of faster economic growth, according to Congressional Budget Office data analyzed by the nonpartisan Committee for a...

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How offshore billing services will impact your practice’s bottom line

Posted by on May 4, 2016 in Latest News | Comments Off on How offshore billing services will impact your practice’s bottom line

By Cody Raich, Executive Data Analyst During the past five years, we have seen many billing companies lower their cost for services.  When this trend is examined, it becomes apparent that the lower cost is available because these billing services are offshoring their services. As medical billing companies increasingly look to offshore their services, many health care providers are now weighing the potential savings of going with an offshore company against the familiarity offered by onshore billers. However, rather than forcing health care providers to choose a side, Vachette Pathology and Stark Medical Auditing & Consulting predict the move toward offshore billing will force onshore billers to lower their rates to remain competitive. I’m often asked, “How do these offshore companies compare?”  This is always an interesting question. I usually tell the client what really matters is not where your billing is done, but how much you actually make.  Now if you want to raise the American flag and tout patriotism while driving your 35 percent foreign car, watching your Korean TV and chatting on your Chinese iPhone I can respect that. But, the bottom line is what actually is going into your American wallet. With your wallet in mind, let’s take a look at an example. Group A is a hypothetical U.S.-based provider whose services totaled $14 million in annual charges for 2015.  Let’s say payments received for charges were $2.7 million and the provider’s charges for onshore billing cost 7 percent of their payments, or $189,000 per year.  Conversely, let’s say offshore billing costs merely 4 percent, or $108,000 per year. Offshore billing cost = 4 percent * ($2.7 million) = $108,000 per year. Onshore billing cost = 7 percent * ($2.7 million) = $189,000 per year. Onshore – Offshore = $81,000 in annual savings (all outside variables held constant). The obvious initial conclusion is that Group A will save $81,000 for the year if they do their billing offshore. As noted in the accompanying graph, if all variables remain constant over a ten-year period, the group would realize a savings of nearly $810,000 by switching to an offshore billing service. However, for a group as large as this, a mere half a percentage point drop in collections will lose a surprising chunk of change ($70,000). In some situations a change in billers can lead to a 2 to 5 percent increase in collections after a switch. Collection % = $2.7 million / $14 million (Percent of charges that were actually collected in payments) For example, 2.7 / 14 = .192 or 19.2% But what if the biller increases the collection percentage?  Based on our projections, that could equal huge gains ($140,000 for every 1 percent increase in collections plus the initial $81,000 would equal a potential of $221,000 more for that year alone). This is the “double whammy” possibility that offshoring your billing presents. Taking this chance and receiving this result could be atypical, but not completely outside the realm of possibility.  If the right dominos fall, doctors and their practices could have a financial bump without additional charges. So why aren’t more practices utilizing this opportunity for savings?  The fact is, many billing services are moving offshore. Sure, they’ll still maintain an office in the U.S., but the actual billing is being done elsewhere.  Still,...

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Vachette Pathology President Mick Raich featured in Part B News!

Posted by on Apr 27, 2016 in Latest News | Comments Off on Vachette Pathology President Mick Raich featured in Part B News!

Trying to decide if an underperforming insurance plan is doing your practice more harm than good? Check out the April 18 issue of Part B News for input from Mick Raich, President of Vachette Pathology & Stark Medical Auditing and Consulting, and other experts who offer up five ways to help determine the overall worth of a plan before cutting ties with it.   Click here to view the article online. (Note: reading the full article requires a subscription to Part B...

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A quality conundrum: How changing CMS reimbursement rates affect patient care

Posted by on Apr 25, 2016 in Latest News | Comments Off on A quality conundrum: How changing CMS reimbursement rates affect patient care

By Jake Vugrinac, Director of Business Development We all read different things for different reasons.  Whether for business or pleasure, our taste in literature is diverse and unique.   Some of us enjoy immersing ourselves in the adventures of boy wizards, the love life of vampires or the impending doom that zombies pose to civilization.  I am not one of those people; I am a numbers guy.  I prefer curling up next to the fire with a riveting essay on sabermetrics in baseball.  And I realize I am in the minority here.  Most “normal” people don’t experience the warm embrace of contentment that can only come from your credits matching your debits.  I feel for people who will live a life devoid of the joy that only regression analysis and data sets can bring.  But today, I will try to bridge the gap between “numbers” people and “normal” people.  Regardless of your reading preferences, we all need to know the consequences that changing reimbursement rates have on health care. 2012 study of nationwide hospital reimbursement data shows higher Medicare reimbursement rates led to an increase in length of care for enrollees. CMS needs to take a good look at their payment structure and reevaluate how it calculates reimbursement rates to eliminate the discrepancy in length of stay between hospitals. Reimbursement changes will continue to send shock waves through hospitals and physicians nationwide and those in the position to make these changes need to be cognizant of that. I recently read a thesis, “Medicare’s Prospective Payment System: Do Differences in the Reimbursement Rate Affect Quantity of Care Delivered and Hospital Billing Practices?”, by Russell Hollis, a graduate of Duke University’s economics program.  This thesis investigated the correlation between changes to reimbursement rates and the quantity of health care received by length of stay.  The scope of this research included 470,000 patients in 2,696 hospitals in 2012.  In order to eliminate variables that could skew the results, the scope was limited to major replacement or reattachment of the lower extremity, DRG 470 (no complications) and DRG 469 (with complications) (Hollis, 2). The question posed is an important one: What effects do changing reimbursement rates have on patient care?  Changes in reimbursement rates are an unavoidable variable.  CMS is running out of money.  Because of this, they are changing the way they pay for hospital care.   By rewarding hospitals for delivering services of higher quality and higher value, they intend to drive down costs.  But to what degree will changes in CMS compensation to hospitals affect the treatment of the Medicare enrollees?  To find this answer, we will have to research how the treatment of patients differs by various hospitals receiving different compensation in Medicare reimbursement for the same diagnosis.  Finding the analytical answer to this question is where it gets a little…dry.  For the convenience and dwindling attention span of my audience, I will skip to the results and leave you to explore the delicate whimsy of regression analysis on your own time. The study found that a 1 percent increase in reimbursement led to a .007 percent (James Bond’s favorite percentage) increase in the length of stay for DRG 470 and a .057 percent increase for DRG 469 (Hollis, 33).  This data shows that even though the correlation may seem small,...

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Case studies: Delayed Medicaid payments, unassigned codes and more

Posted by on Mar 28, 2016 in Latest News | Comments Off on Case studies: Delayed Medicaid payments, unassigned codes and more

Below are some of the latest case studies from the team at Vachette Pathology & Stark Medical Auditing. Case No. 1: Unassigned codes affect annual bonus Problem: A hospital-employed group has a clause in its contract that grants the group a bonus each year if the physicians meet a certain relative-value unit (RVU) threshold. However, the physicians were informed they narrowly missed the threshold in both 2014 and 2015 despite believing they had met their goal. Process: As part of a contract with the group, Stark tracks the RVU threshold on a monthly basis. While examining data in the reporting from their third-party biller back down to the CPT code level, we identified four codes that were not assigned an RVU in 2015 and therefore were not being counted toward the goal. The error was uncovered while the group’s client manager was reviewing a monthly report that showed zero work RVU’s calculated for the codes in question. The find on was then verified by using Medicare’s “Fee Lookup” tool to confirm there were work RVU’s assigned for those codes. After following up to ensure the missing codes were retroactively assigned with RVUs, we expect the group will meet its bonus threshold for 2015. The CPT detail for 2014 also is under review in case similar errors were made. Recommendation: Perform quarterly audits to ensure the integrity of data reporting from your biller. Consider a third-party auditor to verify results. If a group relies on reporting from its biller to submit data for bonuses similar to this, it has only the biller’s assurances that the data is correct. A third-party auditor can track this data regularly to discover reporting issues before they begin affecting your revenue.   Case No. 2:  Delayed start for state managed Medicaid causes payment gaps Problem: A behavioral health provider in Iowa was not receiving Medicaid payments because of the delayed start of the state’s managed care program. Process: The transition from traditional Medicaid to a managed Medicaid product is causing headaches for many behavioral health care providers, as the Iowa provider undergoing this transition can attest. Although CMS planned to launch Iowa’s managed care program in January after terminating the previous managed care organization’s (MCO) Medicaid contract in December, multiple start-date delays from CMS have led to a months-long payment gap. The Iowa provider is part of an association that’s working aggressively to develop contracts with the new MCOs. However, the delay in the start date for the new MCOs created issues because the state program itself (Iowa Medicaid Enterprise) did not create a contingency plan for this delayed start. Because of this lack of foresight, IME is now handling all of the behavioral health care claims processing on a rather outdated technology platform with limited staffing. On top that, IME has been providing different directions for claim filing to each provider, which has required the providers to restructure internal systems to get claims processed efficiently and out the door. “It’s been a huge issue and many providers are just now starting to see payments here in March,” said Jessica Jankowski, executive client administrator for Vachette and Stark. “However, several of their services still aren’t being paid for various reasons that IME has yet to explain.” Recommendation: Start preparing for change now if you know...

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Practices still struggling to get payments from failing insurance co-ops

Posted by on Mar 22, 2016 in Latest News | Comments Off on Practices still struggling to get payments from failing insurance co-ops

By Mick Raich, President, Vachette Business Services Recently, it was noted by Healthcare Finance News that many of the non-profit health insurance co-ops developed under Obamacare have failed to the tune of $1.2 billion.  Yes, this is over a billion dollars lost, never to be seen again. Health care providers throughout the country are owed more than $700 million for services provided to patients of these failed insurance co-ops — the vast majority of which they likely will never see. This makes it more crucial then ever to ensure your practice is diligently tracking payments from co-ops you are contracted with. Where did this money go? Well, it didn’t go to our clients. Many of our groups are owed substantial amounts of money from these failed ventures. For example, the Kentucky Health Co-Op currently is not paying its claims at all. As the practice manager for this client we reviewed the contract and found we cannot balance bill the patients for this service and that the plan is basically bankrupt. So if the providers didn’t get the money, where did it go? The government planned on some of these co-ops failing, but they failed at a rate four times higher then they predicted.  Is anyone going to be held accountable for this? And what about the people who signed up for these plans? Some estimates say 740,000 people lost their initial plans and had to sign up for other plans. What about the inconvenience for these people? There is more than $700 million owed to providers for these services which will never be paid. How do you run a business if you don’t get paid when you deliver services? Who is investigating this for your practice? Why not hire an expert? Call Stark Medical Auditing/Vachette Business Services at 517-486-4262 and ask for Mick Raich. Or, email Mick at...

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Video: Health network consolidation, MIPS signal big changes for private practices

Posted by on Mar 18, 2016 in Latest News, Videos | Comments Off on Video: Health network consolidation, MIPS signal big changes for private practices

Vachette President Mick Raich shares his thoughts on the recent news that the Obama administration plans to begin rating health care networks based on the number of physicians and hospitals within a network and also discusses the new Merit-Based Incentive Payment System that will be used to grade physicians starting next year. Check out our video to learn why these changes are expected to have a major impact on health care providers in the world of private practices and what Vachette can help you do to prepare. If you’re looking for more information on MIPS, click here to download our free white...

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An interesting week in payment thinking

Posted by on Mar 10, 2016 in Latest News | Comments Off on An interesting week in payment thinking

Last week’s health care headlines revealed some interesting trends regarding the ongoing shift toward alternative payment models. Some examples: “HHS hits goal of shifting 30% of Medicare payments to alternative models” — Beckers Hospital Review, March 3, 2016. — Takeaway: As of January, CMS estimates that roughly $117 billion out of a projected $380 billion in Medicare fee-for-service (FFS) payments are tied to an alternative model. “Only 3% of providers feel ready for pay-for-value, HIMSS survey finds” — Healthcare Finance News, March 4, 2016. — Takeaway: A 2016 HIMSS cost accounting survey revealed few providers feel they are “highly prepared” to make the value transition. “Fee-for Service Still Dominates in United States” — Medscape, March 8, 2016. — Takeaway: According to the article, 95 percent of all provider visits are paid via the FFS model, which is actually a 1 percent increase from 2013. Bottom line: Medicare thinks they are receiving 30 percent of payments through alternative payment models even IF these are fee-for-service models. Most practices are actually getting FFS payments — 95 percent, in fact — and everyone feels they are not quite ready for the future. Contact Mick Raich, president of Vachette Pathology and Stark Medical Auditing, at 517-486-4262 or at mraich@vachettepathology.com to learn how our consultants can work with you to make sure your practice is prepared for the ongoing shift toward APMs....

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White Paper: Preparing for the Merit-Based Incentive Payment System

Posted by on Mar 4, 2016 in Latest News, White Papers | Comments Off on White Paper: Preparing for the Merit-Based Incentive Payment System

Medicare Part B providers throughout the country should be preparing to have their performance graded by the new Merit-Based Incentive Payment System (MIPS) starting in January 2017. Understanding each of MIPS’ components ahead of time will be crucial when you’re competing with your peers to earn Medicare reimbursement bonuses and avoid penalties. Check out our free whitepaper to learn the potential financial impact MIPS will have on providers, who is exempt from the program, when CMS is expected to finalize the rules governing MIPS, and much more! To download the white paper, please join our mailing list. We promise not to share your email or send you spam, and you can unsubscribe at any time. First Name (required) Last Name (required) Your Email...

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