Latest News

Medicare auditors’ authority to upcode or downcode has an upside and downside

Posted by on Jun 14, 2015 in Latest News | Comments Off on Medicare auditors’ authority to upcode or downcode has an upside and downside

“With great power comes great responsibility” ~ Voltaire I doubt that Voltaire had medical coding on his mind during the Age of Enlightenment. But in the Age of Coding, his maxim certainly rings true. Starting on May 4th, Medicare auditors added a new dimension to their authority. With the implementation of Transmittal 585, auditors now have the autonomy to change the level of codes billed and still pay the claim; they are able to upcode or downcode claims when a payable service was rendered, yet they believe the provider has selected the...

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UnitedHealthcare Pressures Pathology Groups to Participate

Posted by on May 31, 2015 in Latest News | Comments Off on UnitedHealthcare Pressures Pathology Groups to Participate

Are you familiar with UnitedHealthcare’s Extended Non-Network Reimbursement Program (ENRP)? If you are a pathology group practicing in Texas, Arizona, Florida or Missouri, and you are not participating with UnitedHealthcare, this program applies to you. Here’s the scenario — a patient goes to an in-network facility, yet receives services from an out-of-network pathology provider.  Under ENRP, UnitedHealthcare will pay based on out-of-network rates. Payment will not be 100% of billed charges, and patients could be balanced-billed the...

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Have you seen a decrease in your Anthem payments? This may be why

Posted by on May 20, 2015 in Latest News | Comments Off on Have you seen a decrease in your Anthem payments? This may be why

If you are a provider in the following states, be aware: OH, KY, IN, MO, WI, CT, NH, ME, VA Anthem Blue Cross and Blue Shield began migrating their Medicare Advantage members to a new claims processing system starting in January of 2015. Providers, this new processing system could impact your claims receipt.  Claims are validated as received through the clearinghouse, but Anthem is unable to identify claims submission via their online portal or through customer service. If you have seen a recent spike in your Anthem accounts receivable, and a...

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Billing Transition Issues Concerning Old Receivables

Posted by on May 4, 2015 in Latest News | Comments Off on Billing Transition Issues Concerning Old Receivables

Every year we assist 15 to 20 clients as they transition from one billing firm to another.  The reasons for these transitions are varied; usually it boils down to a lack of performance followed by a lack of communication, sometimes both. One of the big issues we see in these transitions is the handling of old receivables from the previous billing company.  Often the original biller works these claims for three months, then rolls them off to collections. But what next? You should ask yourself: What does your billing contract state regarding...

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Out-of-Network Labs, Pathologists May Have Some Recourse Against Insurers

Posted by on Apr 30, 2015 in Latest News | Comments Off on Out-of-Network Labs, Pathologists May Have Some Recourse Against Insurers

Out-of-network (OON) laboratories and pathologists who have been underpaid by insurers now may have some recourse. Two recent court rulings appear to clear the way for OON providers to sue insurers in federal court. As insurers increasingly narrow their networks, more and more providers find themselves on the outside looking in, fighting to receive appropriate payment for the services they provide. For years now, insurers have tried to limit payment to providers and discourage out-of-network utilization through higher patient deductibles and...

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The Impact of H.R. 2 on Your Practice & What You Need to Do

Posted by on Apr 28, 2015 in Latest News | Comments Off on The Impact of H.R. 2 on Your Practice & What You Need to Do

Since the Senate approved the H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015 and averted a 21% pay cut, CMS announced an effort to minimize financial effects on providers: They would institute a 10-business day processing hold for all impacted claims with dates of service April 1, 2015, and later. On April 15, 2015, CMS announced that these held claims would begin processing with the negative rate update on a first-in, first-out basis as of April 15. Meanwhile, they will continue to hold new claims as they are received. The H.R....

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The Shifting Self-Pay Revenue Cycle and its Relationship to U-6 and U-3 Unemployment Rates

Posted by on Apr 1, 2015 in Latest News | Comments Off on The Shifting Self-Pay Revenue Cycle and its Relationship to U-6 and U-3 Unemployment Rates

By John Berry and Mick Raich Vachette Pathology Many practices, hospitals and health systems are searching for answers to collecting their self-pay dollars, and with good reason. There has been a huge shift in self-pay financials over the last seven years. Most of our clients have seen their self-pay collection percentages go from 15-20 percent to less than 10 percent. What is the cause behind this change, and why has self-pay not rebounded with the recent financial upturn touted by the government? Perhaps the economy, specifically the...

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The SGR ‘Fix’ and How It Affects Your Practice Revenue

Posted by on Mar 27, 2015 in Latest News | Comments Off on The SGR ‘Fix’ and How It Affects Your Practice Revenue

Recently H.R. 2 was passed in the House, the Medicare Access and CHIP Reauthorization Act of 2015.  This would permanently repeal the SGR formula and replace it with a formula that will give half of one percent increases for the next five years, and then move all physicians into the value-based payment program. The bill is now in the Senate.  The bill has to pass before April 1st to prevent a 21% pay cut from Medicare, and the Senate is scheduled to go on break today until April 13th. What this effectively means is physicians’ payments are...

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White Paper: Business Strategy for Pathology Practices and Independent Laboratories

Posted by on Mar 17, 2015 in Latest News | Comments Off on White Paper: Business Strategy for Pathology Practices and Independent Laboratories

Recently, I was asked to speak at the G2 PathForward Symposium about business strategies for pathology practices and independent laboratories, including issues such as mergers and acquisitions, the ACO movement, revenue, and managed care changes. My goal was to look at strategies over the next one to five years and offer some action steps that conference attendees could use to prepare for the future. For those who missed the symposium, I’ve collected the main points of my presentation in a new white paper, “Business Strategy for...

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Another Round of Payment Denials with IHCs, 88341 and the Prostate G Codes

Posted by on Mar 13, 2015 in Latest News | Comments Off on Another Round of Payment Denials with IHCs, 88341 and the Prostate G Codes

It seems our latest audit has caught a glitch in Medicare Immunohistochemistry (IHC) payments. We found that Cahaba GBA, which serves as the Medicare administrative contractor for Alabama, Georgia, and Tennessee, is denying claims for CPT code 88341 as multiples, using various denial codes: MA15 – Your claim has been separated to expedite handling M53 – Missing/incomplete/invalid days of units of service M59 – Missing/incomplete/invalid “to” dates of service MA130 – Your claim contains incomplete and/or invalid information, and no appeal...

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