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Prostate biopsy, flow cytometry cuts finalized in 2018 Medicare Physician Fee Schedule

Posted by on Nov 6, 2017 in Latest News | Comments Off on Prostate biopsy, flow cytometry cuts finalized in 2018 Medicare Physician Fee Schedule

Prostate biopsy, flow cytometry cuts finalized in 2018 Medicare Physician Fee Schedule

Pathologists who are still reeling from proposed PAMA-induced cuts for next year’s clinical lab fee schedule should be relieved to learn CMS made few significant changes to key pathology codes on the final 2018 Physician Fee Schedule. The most significant adjustment from the proposed rule that was released earlier this year involves a bump to 88184 (flow cytometry, first marker). After initially proposing a slight cut from 2017 rate of $61.73, CMS backtracked and instead elected to boost the payment for 2018 to $68.02, an increase of 9.2 percent. Beyond that change, most codes saw only minor adjustments of roughly a percent from what was proposed earlier this year. As expected, the biggest hits will 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. The other key cuts 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 percent reduction to $88.90. Perhaps most surprisingly, CMS also announced it will reduce the 2018 Value Modifier penalty for those who failed to meet 2016 PQRS criteria from negative 4 percent to negative 2 percent for groups of 10 or more, and from negative 2 percent to negative 1 percent for groups of two to nine. Similar to reducing the number of required quality measures under PQRS from nine to six, CMS said the changes to the Value Modifier penalties were made to better bring the program in line with current Merit-based Incentive Payment System requirements. The final conversion factor for 2018 is 35.9903, a slight bump over the 2017 rate of $35.8887. The overall update to payments under the PFS based on the proposed 2018 rates is .41 percent. The update reflects the .5 percent annual increase established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by -.09 percent due to the misvalued code target recapture amount, according to CMS. CPT Code Service Final 2018 Current 2017 Change 88112 – Global Cytopath cell ehance tech $70.18 $68.91 1.8% 88112 – TC Cytopath cell ehance tech $40.67 $39.84 2.1% 88112 – 26 Cytopath cell ehance tech $29.51 $29.07 1.5% 88121 – Global Cytp urine 3-5 probes cmptr $541.65 $553.76 -2.2% 88121 – TC Cytp urine 3-5 probes cmptr $489.64 $501.72 -2.4% 88121 – 26 Cytp urine 3-5 probes cmptr $52.19 $52.04 0.3% 88184 – TC Flowcytometry/ 1st marker $68.02 $61.73 9.2% 88185 – TC Flowcytometry/ additional marker $30.59 $37.68 -18.8% 88189 – 26 Flowcytometry/ read 16+ $88.90 $92.59 -4.0% 88305- Global Tissue exam by pathologist $70.18 $69.62 0.8% 88305 – TC Tissue exam by pathologist $30.23 $29.79 1.5% 88305 – 26 Tissue exam by pathologist $39.95 $39.84 0.3% 88307 – Global Level V, tissue exam by pathologist $269.93 $269.88 0.1% 88307 – TC Level V, tissue exam by pathologist $182.11 $181.96 0.1% 88307 – 26 Level V, tissue exam by pathologist $87.82 $87.93 -0.1% 88309 – Global Tissue exam by pathologist $409.93 $413.80 -0.9% 88309 – TC Tissue exam by pathologist $254.09 $258.40 -1.7% 88309 – 26 Tissue exam by pathologist $155.84 $155.40 0.3% 88312 –...

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Deadline approaching to request PQRS informal review!

Posted by on Oct 20, 2017 in Latest News | Comments Off on Deadline approaching to request PQRS informal review!

Deadline approaching to request PQRS informal review!

Have you reviewed your 2016 Physician Quality Reporting System (PQRS) feedback report and Quality Resource Use Report (QRUR) yet? Keep in mind that you now have less than two months before the Dec. 1 deadline to submit a request for an informal review if you feel your group has been unfairly penalized. Unlike the new Quality Payment Program, PQRS does not offer incentives to strong performers. Instead, groups and individuals who failed to report six quality measures across three National Quality Strategy domains (unless exempted by a MAV), will receive a negative 2 percent payment adjustment on Medicare claims paid under the MPFS in 2018. The reduction from nine to six measures was announced by CMS earlier this year as part of an attempt to bring the final year of PQRS in line with current Merit-based Incentive Payment System requirements. Additionally, groups will also be hit with the Value Modifier penalty in 2018 if fewer than 50 percent of their PQRS participants failed their 2016 reporting. Groups of nine or fewer physicians will receive an additional 2 percent penalty, while groups of 10 or more would see a whopping 4 percent reduction on top of the PQRS penalty! Both PQRS feedback reports and QRURs can be reviewed through the CMS Enterprise Portal using your Enterprise Identity Management account. As with other CMS programs, mistakes are made! That’s why it’s important to submit a request for a review if you have any questions concerning CMS’s methodology for assessing a penalty. Vachette has assisted numerous clients with this process since PQRS was first implemented and will gladly offer our expertise to groups who may be facing a penalty for the first time. Don’t let laziness be an excuse for not protecting your Medicare...

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PAMA proposed to have heavy impact on 2018 clinical lab tests

Posted by on Sep 28, 2017 in Latest News | Comments Off on PAMA proposed to have heavy impact on 2018 clinical lab tests

PAMA proposed to have heavy impact on 2018 clinical lab tests

The cuts many have long predicted for clinical lab tests paid under the Medicare Clinical Laboratory Fee Schedule are likely to hit bottom lines hard next year if preliminary 2018 rates released Sept. 22 don’t see significant changes prior to being finalized. However, CMS is already receiving significant pushback on its proposal from stakeholders who believe the private-payer data these changes are based off is skewed. Quick hits: Total cuts proposed at roughly $670 million, a decrease of nearly 10 percent. 75 percent of tests will have price reductions, with 58 percent having phased-in decreases because of annual reduction cap. Automated tests taking the largest hit. Many high-volume tests also saw substantial cuts. Molecular tests not hit as hard as anticipated, with a few even seeing increases. Quest Diagnostics threatening a lawsuit. Public comments to be accepted through Oct. 23, with final rule expected in early November. All proposed changes are derived from payer data CMS gathered earlier this year during the inaugural reporting period for the Protecting Access to Medicare Act (PAMA). Rate changes were based on data reported by 1,942 laboratories. Of those, 658 were independent labs, 1,106 were physician office labs, and 157 were urgent care centers, hospital inpatient labs, or “other.” Only 21 hospital labs were required to contribute to the total, due to the fact that an exemption was granted to labs that didn’t have a NPI that collects more than 50 percent of its Medicare revenue during the collection period under the MCLFS or MPFS. It should also be noted that just over 90 percent of the total test volume reported came from independent labs. As part of PAMA, cuts to individual tests are cap at 10 percent annually for the first three years (2018-2020) and will be capped at 15 percent annually over the program’s final three years (2021-2023). Unsurprisingly, Quest Diagnostics has already issued a press release expressing their displeasure with the proposed rates. “We are deeply disappointed that CMS has issued draft 2018 Medicare payment rates that are not market-based and derived from flawed market data collection that excluded key components of the lab market,” Steve Rusckowski, Chairman, President and CEO of Quest Diagnostics, said in the release. Ruchowski went on to say he “fully supports” the American Clinical Laboratory Association’s plan to explore legal options, if necessary. Labcorp Chairman and CEO David King also stated his company’s opposition, calling the PAMA reporting process “fatally flawed” in a press release. King particularly took issue with the fact that the data was pulled from a pool that represented just 1 percent of the overall labs in the U.S. In short, while it would be a shock to see CMS admit fault and completely toss out the proposed rates, the pushback the agency is receiving may prompt significant changes from what is currently on the table. Check out the chart below for a breakdown of the major proposed changes for the top 20 CLFS codes from 2016. (A full list of affected codes can be downloaded here: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-28-enews.html#_Toc494273320) Code Service 2017 Medicare NLA Weighted Median Full Change 2018 Rate W/ 10% Cap 84443 Assay thyroid stim hormone $23.05 $14.87 -35% $20.75 80053 Comprehen metabolic panel $14.49 $9.08 -37% $13.04 85025 Complete cbc w/auto diff wbc $10.66 $6.88 -35% $9.59 80061 Lipid panel...

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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...

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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...

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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...

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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...

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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...

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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...

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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...

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