Mick Raich, Vachette Pathology
Earlier this year I wrote a brief article on the changes with 88342 and the new G codes G0461 and G0462. This article proved very insightful to me and many others. It helped me understand how I was looking at things incorrectly, and it helped our client practices understand their revenue shortfalls.
It has been six months since that piece; let’s take a quick look back at the revenue losses we predicted, compared to actual loss. Remember this is only for Medicare payments.
We reviewed a lab which bills globally and predicated a loss of $159,000. Originally we figured their losses as of May 2014 would be about $16,611. In actuality, their loss is $16,248. See the graph below.
For a group which bills professionally, we only predicted a loss of about $14,000 by May 2014. In actuality the loss is $19,000. See the graph below.
As you see with these two examples, most of our loss predictions were less than actual losses. When tracking these things you have to be careful to look at date of service data and to look for claims that have already been fully adjudicated.
We find that many of our groups and their billers are still suffering from a bad process to handle these cases.
We have about 70 groups, labs and hospitals under contract, and we provided these projections to them last year. Currently we are tracking losses for all our clients. We are also aggressively auditing our clients each quarter to find missing and denied cases that have not been appealed. There are millions of dollars left on the table in this area.
Here is exactly what you should do to track these cases and prevent these losses.
Sample IHC Auditing Process
1. Request cases from physician.
a. Request an appropriate number of pathology reports that have IHC CPT codes assigned. (Please note our groups are auditing ALL of their IHC cases.)
i. Dates of service should be at least six months prior to the audit start date.
ii. Reports should be randomly selected (the biller should NOT be involved in the selection process).
2. Receive initial cases from physician.
3. Send initial cases to biller requesting the following documentation:
a. HCFA form;
b. explanation of benefits from primary and secondary insurance with adjustment codes;
c. and patient transaction or history screen that shows payment and adjustment posting and current balance.
4. Receive initial case information from biller.
5. Match case information.
a. Attach the biller’s documentation to the pathology report received from the physician’s office.
b. Compare reported IHC CPT codes to billed CPT codes to confirm the correct CPT codes have been billed according to IHC guidelines.
c. Confirm correct number of units have been billed to carrier according to IHC guidelines.
d. Confirm correct IHC CPT codes were billed to Medicare or the insurance carrier according to insurance carrier guideline. (This is the hard part and where you must build a matrix to review each carrier.)
e. Confirm date of service to verify correct IHC CPT codes were billed to carrier per IHC guidelines.
f. Confirm insurance is allowing all units billed for IHC CPT codes.
g. Compile questions that require further explanation from biller.
6. Send initial questions to biller.
7. Receive question documents back from biller.
a. Review answers from biller and document case audit finding.
8. Complete case audit.
a. Categorize case audit findings and report in audit summary.
9. Perform payer analysis by EOB.
a. Confirm IHC CPT allowed amounts by insurance are being paid according to the managed care contract reimbursement language.
10. Track every case to payment or bad debt and zero balance
The best option is to audit your billing, then work forward.
I will release a final version of this comparison in February of 2015 to review actual dollars lost compared to our total predictions.
Although these types of predictions are not always 100% correct, it is important to at least considering your losses and be proactive. For example, next you should be looking at the proposed CMS fee schedule for 2015 and building projections for those cuts.
If you have any questions please contact me, Mick Raich, at 866-407-0763 or 517-486-4262 or email@example.com.
It appears Blue Cross and Blue Shield of Minnesota (BCBSMN) has made a significant error in Medicare reimbursements and has just recently realized it.
In May 2014, BCBSMN notified providers they will begin withholding a 2% Medicare payment reduction mandated by sequestration to all claims processed after June 6, 2014 — even though sequestration began April 1, 2013.
Plus, BCBSMN will be recovering the 2% reduction on Medicare claims with dates of service October 1, 2013, and later. However, they will only be targeting claims with a net payment of $100 or greater.
Sorry pathologists – their error is now your problem. Claim adjustments began the week of June 16, 2014. Look for your BCBSMN payment to decrease.
View the notification at:
As an auditing and practice management firm that works with pathology groups, laboratories and hospitals in Minnesota and across the nation, Vachette urges you to ensure your billing company is watching this, as well as verifying the 2% reduction in other Medicare Advantage plans.
If you have questions, please feel free to contact us at 866-407-0763.
Follow me, Vachette President Mick Raich, on LinkedIn to see more auditing updates.
Wendy Payette, Director of Auditing
Vachette Pathology / Stark Medical Auditing
Our clients are asking about a new phenomenon — insurance companies who send an explanation of benefits (EOB) with “virtual” payment. The EOB will state, “payment for this remittance is being made via virtual credit card; please process this payment as you would any credit card.”
This brings up several areas of concern. First, what if you don’t take credit cards? Some practices have not progressed this far, and they do not have the ability to accept these virtual payments.
Second, you have to pay a fee to get this money; whenever you process credit card payment, you are charged a merchant fee, typically 2.5-3%. This fee comes out of your payment, lowering your margin.
Also, unlike other credit card payments, you must make a call to get paid. Calling the payer to get the amount approved takes time.
Finally, these virtual credit cards expire after about two months. This means if you don’t call and process the transaction, you lose the payment entirely.
Why do payers use virtual credit cards? By not sending a check, they may actually be hoping the biller will never make the call, therefore they do not have to pay the physician. Remember, calling the payer actually increases the cost of billing.
The simpler and easier thing to do is to sign up for electronic funds transfer (EFT) for payments. This makes the payment process much easier and eliminates the merchant fee altogether.
Do you have questions about virtual credit card payments? Contact Mick Raich, President of Vachette Pathology and Stark Medical Auditing at 866-407-0763.
By Michelle Miller, Vice President
June 13, 2014
During a recent audit for one of my clients, I was working through some random CMS denials and noticed that several special stains had been denied. There were eight units billed and ALL had been denied by CMS and adjusted by the biller. Yet I know that the CMS National Coverage Determination (NCD) allows billing for one unit – why was that unit not approved?
I spoke with the billing agency and was informed that CMS will typically deny ALL charges — even if one should be approved — until the appeal is made. If the documentation supports the additional units, then CMS will make payment on all the unit(s).
Typically, when a biller receives a denial letter from CMS, they begin to step through the five levels of appeal, starting with Redetermination. The biller sends copies of supporting documentation for the denied CPT code(s), and if the documentation supports medical necessity, CMS will make payment. If not, the denial is upheld, and the biller will move on to the next level of appeal, Reconsideration, and so on down the line until the claim is paid, or all levels of appeal have been exhausted.
There is one key factor to the CMS appeals process – the initial Redetermination request must be filed with 120 days of the initial denial.
The denials I reviewed were from December 2013. The date today is May 16, 2014. The billing agency failed to appeal the denied charges within the allotted 120 days. At this point, we’ve lost out not only on getting paid for all units billed, but also on getting paid for the one allowed unit.
While these denials are for CMS, imagine how many this billing agency receives for the rest of the insurance carriers they file to. What are each carrier’s appeal rules? Have we missed any other filing limits for the appeal process? How much money is lying on the table right now?
Who’s watching your denials? If you do not regularly review and discuss denial reporting with your billing agency, you will lose revenue. The billing agency should be able to provide feedback and information regarding the denials they are receiving from all insurance carriers they bill.
Michelle Miller is the Vice President of Vachette Pathology and Stark Medical Auditing. Our company specializes in auditing billing for hospitals, independent testing facilities, and hospital-based providers. Visit our websites: www.vachettepathology.com and www.starkmedicalauditing.com. Our direct line is 866.407.0763.
By Jessica Jankowski, Senior Practice Manager Vachette Pathology
Since January 2014, there are more and more issues coming out of the woodwork with FSH billing and reimbursement. Earlier this year, we saw United Health Care (UHC) create their own application of an MUE to any CPT Code 88368 billed more than once per patient per day. While UHC is now in the process of recanting this, we are continuing to see Blue Cross Blue Shield of South Carolina (BCBS SC) deny 88368 as investigational.
According to BCBS SC, they are taking issue with an assay component used in some FSH testing that requires a more “clear association with clinical outcomes” (Blue Cross Blue Shield South Carolina , 2013). The policy goes on to further state that “the clinical utility of the HERmark® assay has not been demonstrated, and clinical trials are needed to determine the impact on the clinical outcome of patients stratified by the HERmark® assay” (Blue Cross Blue Shield South Carolina , 2013).
There are two problems that I see in this policy:
1) The policy is based on the use of the HERmark® assay for FSH testing and only this assay, and
2) The HERmark® assay test is not an FDA-approved test; it is considered a homebrew test (Blue Cross Blue Shield South Carolina , 2013).
My question to BCBS SC is, how can they assume every FSH test done by a pathologist uses only the HERmark® assay? And one that is not even FDA-approved? Can they truly believe this is the only method? In fact, there are other FDA-approved FSH assays being used, such as PathVysion™, Inform®HER2/neu and as well as Dako’s HER2 IFSH pharmDx™ assay technology (FDA, 2010).
In an effort to appeal the denials of BCBS SC, we recommend that billers provide data showing the type of FSH assay used, as well as information validating the FDA-approval of the assay.
For further information contact Jessica at Vachette Pathology 517-486-4262.
Blue Cross Blue Shield South Carolina . (2013, December). Medical Policies . Retrieved June 2014, from http://www.cam-policies.com
Dako. (2013, February ). Dako: an Agilent Technologies Company . Retrieved June 2014, from About Dako : http://www.dako.com
FDA. (2010, October ). Medical Devices . Retrieved June 2014, from U.S food and Drug Administration : http://www.fda.gov
Merged accounts: We have found several hospital based practices where they have “merged” accounts. This means two separate patient visits where merged together. The problem is the CPT codes were not merged. Take a look closely at your hospital based billing, your system may be merging accounts and you may be losing money.
Communication! We found a situation where the biller was told “do not bill cases that are not coded these are No Charge cases.” Well our audit found that 2% of all the cases were showing up not coded and that most of these should have actually been charged! In this case it was approximately $900,000 a year in lost charges. Ouch.
The biller missed a fee schedule change (approved to be effective 2/1/13 – system did not capture new charges and this was not identified by biller until January of 2014). This resulted in a settlement amount of $7000 for the client!
CMS recently redesigned their claim form so it could handle ICD-10 codes. We all know what happened to the ICD-10 deadline. We are seeing denials because some payers do not accept the old claim form. (CMS–1500 version 02/12 replaced version 08/05.)
We are finding some payers are denying claims billed under the older form, for example: As of 4/1/14 Florida Medicaid providers must use this new version of the form. Also, Total Claims Administration will no longer accept the CMS-1500 claim form (version 08/05) beginning April 1, 2014.
Recently we were asked by a large national billing service, “why would the medical practice hire you?” Later that week we audited one of their practices and found where the same biller had underpriced the client’s fee schedule to the tune of $12,000. This finding alone almost paid for the entire audit. That is EXACTLY is why people hire us.