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MIPS 2019 Proposed Rule: What pathologists should watch for

Posted by on Jul 26, 2018 in Latest News | Comments Off on MIPS 2019 Proposed Rule: What pathologists should watch for

MIPS 2019 Proposed Rule:  What pathologists should watch for

While many groups have yet to fully turn their attention to fulfilling their 2018 Merit-based Incentive Payment System reporting requirements, CMS already has an eye on the 2019 reporting year and beyond. A number of changes for the program were recently proposed along with the 2019 Medicare Physician Fee Schedule Proposed Rule, although could still be revised before the agency releases the final rule late this fall. For now, here’s a breakdown of the most significant proposals to keep on your radar: Claims-based reporting finally being phased out • CMS stated its intention to eventually eliminate the Medicare Part B claims-based reporting process in 2017, so it’s no surprise to learn the agency is proposing to restrict the process to small groups of 15 or fewer physicians next year. That means those in large groups who have relied on claims reporting in the past will need to seek out another method to submit their quality data, such as a qualified reporting registry. Category weighting remains stable for non-patient facing specialists • Fortunately, the proposed rule has not changed the definition of non-patient facing specialists or altered the reporting exemptions offered to these providers since the inaugural MIPS reporting year in 2017. That means most pathologists will again receive 85 percent of their overall MIPS score through their quality reporting, while the final 15 percent can be earned by attesting to one high-weighted or two medium-weighted improvement activities. Non-patient facing specialists will again be exempt from the new Promoting Interoperability (formerly Advancing Care Information) and Cost categories. Pathology claims-based quality measures set to be retired • As part of the move away from claims-based reporting, CMS is also attempting to retire a number of quality measures it considers to be topped-out (ie: have a very strong reporting rate, leaving little room for qualitative judgement between physician submissions). Of the eight existing measures in the pathology specialty measure set, the following three were proposed for elimination: What does this mean for the average group? If you’re a small group who plans to continue reporting via claims, you’ll have three fewer available options to report on in the Quality category. While MIPS typically requires participants to report on six quality measures, specialists with a limited selection are only required to report on measures that apply to them. However, those reporting via the College of American Pathologists Pathology Quality Registry will have access to its expanded selection of quality measures that are available because of the registry’s status as a Qualified Clinical Data Registry. Payments and bonuses increase along with performance threshold • While this is set in stone by MACRA legislation, it’s important to remember the stakes of successfully reporting will again be ramped up. Physicians can earn a bonus or penalty of up to 7 percent in the 2021 payment year based on their participation in the 2019 MIPS reporting year. However, CMS is also proposing to raise the bar to avoid a penalty from 15 points to 30 points, meaning a stronger score would be required to enter bonus territory than in years past. Addition of facility-based scoring mechanism • For the first time, CMS is proposing to allow some facility-based groups to receive a collective quality score for their hospital rather than requiring them to report through the traditional...

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Independent labs eye boon as CMS proposes to increase TC rates for key pathology services

Posted by on Jul 16, 2018 in Latest News | Comments Off on Independent labs eye boon as CMS proposes to increase TC rates for key pathology services

Independent labs eye boon as CMS proposes to increase TC rates for key pathology services

After a slight delay, CMS released its Proposed 2019 Medicare Physician Fee Schedule late Thursday and unveiled a host of payment bumps for the technical components of several key pathology codes. The agency proposed a roughly 8.5 percent hike for 88305-TC, which would see the payment jump to $32.81, while the code’s global rate is proposed to see a 2.7 percent increase to $72.09. However, a 1.7 percent reduction was proposed for the professional interpretation — dropping the payment to $39.29 — a move that largely foreshadowed CMS’s decision to slightly cut professional rates while boosting technical and global components for most major pathology codes. The most significant cuts will again impact prostate biopsies, with the technical rate for G0416 being hit the hardest by a proposed 18.9 percent cut to $200.80. Meanwhile, the global rate would also see a 12 percent cut down to $384.29, while a proposed 1.8 percent reduction for the professional rate would lower the payment to $183.49. Flow cytometry services will also experience heavy reductions, the most significant of which includes an 18.6 percent drop for 88185 (additional markers) to just $24.89. Reads for the first marker or 16-plus are also proposed to experience cuts of 2.5 and 1.9 percent, respectively. The final conversion factor for 2019 is $36.05, a slight bump over the 2018 rate of $35.99. The overall update to payments under the MPFS based on the proposed 2019 rates is .13 percent. The update reflects the .25 percent annual increase established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by -.12 percent for a RVU budget neutrality adjustment, according to CMS. The total scope of the proposed changes will see pathologists’ Medicare rates cut by 1 percent, while independent labs technical rates will jump by 4 percent overall. Finalized rates are expected to be announced in the fall, which rate changes taking effect Jan. 1, 2019. Other notable pathology updates As CMS continues to defend rate reductions in the Clinical Laboratory Fee Schedule triggered by the required reporting of private payer rates under the Protecting Access to Medicare Act, the agency has signaled it may be rethinking its methodology as it is now soliciting comments on whether it should expand the scope of laboratories required to report. While the narrow definition of an “applicable laboratory” resulted in pricing data being primarily gathered from national labs, CMS is now asking pathologists and industry stakeholders whether hospital outreach and physician office labs should also be included. During the inaugural reporting period in 2017, CMS only required data from labs who received more than 50 percent of their Medicare revenue from the CLFS under their own NPI, an exclusion that left hospital labs billing under their hospital’s NPI on the outside. Now, CMS is considering allowing labs to use a CMS-1450 bill type 14x or CLIA certificate numbers to determine whether or not they are an applicable lab. However, CMS also indicated that it feels its current collection process is adequate and that expanding the definition of an applicable lab to include more hospital labs is strictly a proposal at this point. The agency also expressed concern that these reporting requirements could place a large administrative burden on smaller labs who have difficulty collecting this data. The next data collection period...

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Payment cuts for pathology, radiology proposed by MedPAC

Posted by on Jun 18, 2018 in Latest News | Comments Off on Payment cuts for pathology, radiology proposed by MedPAC

Payment cuts for pathology, radiology proposed by MedPAC

Payment cuts for several specialties — including pathology and radiology — could soon be on the horizon after the Medicare Payment Advisory Commission (MedPAC) proposed Congress implement several cuts to offset recommended increases in an attempt to “rebalance” the Medicare Physician Fee Schedule (MPFS). In its June report to Congress, the advisory commission suggested a one-off adjustment to the fee schedule that would see payment rates for evaluation and pain management increase by 10 percent. To offset this increase, MedPAC is recommending a 3.8 percent cut to other services, including diagnostic radiology, pathology and physical and occupational therapy, according to the report. If implemented as proposed, payments for evaluation and management services would increase by $2.4 billion, with endocrinology, rheumatology, and family practice seeing the highest proportional increases. Meanwhile, diagnostic radiology, pathology, and physical and occupational therapy would experience the 3.8 percent cuts “because they provide very few ambulatory and E&M services,” according to the report. In case you haven’t been paying attention throughout the past decade, this is yet another reminder that the fee-for-service world of yesterday is rapidly dissolving as the push toward reimbursements based on quality and value continues. MedPAC Executive Director Jim Mathews clarified this recommendation comes as a direct result of the commission’s belief that imaging exams, procedures and tests, among other services, are overvalued in comparison to evaluation and management services. “We feel that although the effort to identify and correct misvalued services has made incremental improvements to physician payment accuracy in the fee schedule, these improvements have been largely overshadowed by what we call ‘passive devaluation’ of evaluation and management services,” Mathews said in during a June 15 call with the press. MedPAC also hit on the issue of what it terms “low-value care”, such as imaging examinations, that the commission believes are being used too broadly. The commission went on to propose six ways Medicare could address the problem of low-value care: Expand prior authorization. Implement clinical decision support and provider education. Increase cost-sharing for low-value services to reduce their use. Establish new payment models such as accountable care organizations that create incentives for reducing the use of low-value services. Evaluate coverage determinations on an ongoing basis. Link information on cost and clinical effectiveness of healthcare services to fee-for-service coverage and payment policies. The report concluded with another call to revise the quality measures of the Merit-based Incentive Payment System to include more population-based and patient-experience measures that could be scored against a benchmark as opposed to the current scoring model that pits providers against one another. This is just another reminder that groups who are sticking their heads in the sand while clinging to the fee-for-service world of yesterday are only expediting their obsolescence in this value- and outcome-based...

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Is blockchain health care’s next major disruptor?

Posted by on Jun 15, 2018 in Latest News | Comments Off on Is blockchain health care’s next major disruptor?

Is blockchain health care’s next major disruptor?

Let’s face it: the current state of information and data sharing in health care is broken. With numerous electronic health record systems with varying languages and capabilities being employed throughout the country, finding a uniform way to access and share key data is much more cumbersome than one would expect in the 21st Century. However, there’s an efficient solution on the horizon that’s currently being overlooked, says Jacob Vugrinac, CEO and Founder of PolyBlock Investments, a cryptocurrency and blockchain technology investment firm. Vugrinac envisions a system in the near future that would allow patients to have their medical and pharmaceutical information stored as data points in a blockchain decentralized ledger, similar to ones tracking the transactions of Bitcoin and other cryptocurrencies. But, instead of strictly recording financial transactions, this blockchain would store medical information in a cryptographic database operated by a network of computers that could be accessed by health care professionals utilizing the appropriate software. “Blockchain will eventually be applied to health care due to the crazy inefficiency we currently see in terms of data sharing,” Vugrinac says. “It’s hard to imagine now, but Blockchain will have a bigger impact on the world than the internet did.” Blockchain data points are inherently unique and cannot be copied, which means everyone using the system has access to the data it stores, but not the ability to alter the original reference point. Billing and patient data could also theoretically be married together into a single system, a step that Vugrinac says would be huge for the industry as a whole. But, if that sounds too good to be true, Vugrinac understands the skepticism. Currently, blockchain technology is an abstract concept to the average layperson, not unlike the internet and email in the 80s, says Vugrinac. “Back then, people really thought letters were good enough,” Vugrinac says with a smile. “Fast forward to today, and I couldn’t do my job without email.” So, what will it take to help people understand the true potential of blockchain? It’s going to take an “AOL moment”, according to Vugrinac. “When everyone got those AOL CDs in the mail, providing them with simple internet access, that’s when they finally got online and got their heads around the concept and potential of the internet,” he explains. “The internet had existed for years, but until everyone had easy access, they just didn’t understand it.” Currently, the only truly prominent mainstream blockchain is the one tracking Bitcoin. Before this technology can disrupt health care, a single platform will need to emerge as the dominant player, Vugrinac says. “The technology is lagging behind what we want to do with it,” acknowledges Vugrinac. “The hope is that we will eventually get down to a system that the hospitals will agree on, although I expect a few competing players battle for dominance in the market early on. “But, the question of the day is which one will be Netscape and which is amazon?” While it may be too soon to answer that question, Vugrinac says he is sure of one thing about this technology’s potential to disrupt the health care industry. “The doctors and hospitals who are quick to embrace this technology and truly understand how it will help them centralize and store their data are really going to have a...

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Carrier’s confusion over third-party policy causes improper denials

Posted by on Jun 5, 2018 in Latest News | Comments Off on Carrier’s confusion over third-party policy causes improper denials

Carrier’s confusion over third-party policy causes improper denials

As labs across the nation continue to adjust to requirements of recently implemented prior-authorization programs, it appears the private payers partnering with these services are experiencing some confusion as well. While conducting a recent billing audit for a South Carolina-based pathology group, we found several accounts that were allowed at less than the anticipated reimbursement amount. When reviewing these cases with our client’s biller, we determined the issue was stemming from an apparent limit on 88305 units. In one instance, the group billed 13 units, but the carrier processed the allowed amount as only six units, according to the EOB. When questioned on this decision, the carrier responded by referencing a suggested policy from their prior-authorization partner stating prostate biopsies will be capped at six units to prevent fraud and abuse. The issue? The carrier later clarified it had never officially adopted the policy, which means there should not have been denials related to it. However, the carrier was equally confused when it discovered that despite the 13 unites being submitted, only the six that were eventually paid were received by their system. The carrier was unable to explain what caused the number of units to be automatically reduced, but is now digging into the issue based on our discovery. In total, we worked with our client’s biller to find 81 accounts that fell outside the expected allowed amount based on this issue. While we expect to have clarification from the carrier soon, who knows how long this issue would have gone undetected had our client not engaged us to review their...

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Maximizing revenue under the BCBSM incentive program

Posted by on May 15, 2018 in Latest News | Comments Off on Maximizing revenue under the BCBSM incentive program

Maximizing revenue under the BCBSM incentive program

Did you know? Blue Cross Blue Shield of MI withholds 5 percent of all commercial payments. That means even if you’re earning 100% of the standard fee schedule, you’re still losing 5 percent! Pathology value-based reimbursement For years, BCBSM has operated a quality incentive program to realign provider reimbursement with quality of care standards in an effort to control health care costs. Bonus reimbursement earned through the program is referred to as value-based reimbursement (VBR). Pathologists who participate in the Physician Group Incentive Program (PGIP) and meet defined criteria are eligible for reimbursement using the VBR Fee Schedule. The VBR Fee Schedule sets reimbursement rates for specific procedure codes to allow you to earn more than 100 percent of the standard fee schedules. From March 1, 2018 to February 28, 2019, 153 pathologists are receiving a VBR bonus, according to BCBS of MI. VBR Metrics:   Why are population metrics used? According to BCBS, these metrics: Promote the PGIP principle of a community of caregivers’ shared responsibility for a population of patients. Encourage communication and collaboration between primary care and specialty practitioners. Encourage a focus on system performance, accountability and improvement. Promote optimal quality, efficiency and health care utilization in the population of patients. How to participate: Pathologists must be nominated by their member physician organization and must have been in PGIP for one year. The top two-thirds of non-pediatric specialist practices are based on the pathologist weighted composite score and are reimbursed in accordance with the VBR Fee Schedule Practices that serve a small number of Blue Cross patients cannot be evaluated and ranked. VBR bonuses: Practices in the top third of non-pediatric practices are reimbursed at 110 percent of the Standard Fee Schedules. Practices in the second third of non-pediatric practices are reimbursed at 105 percent of the Standard Fee Schedules Practices in the bottom third of non-pediatric practices are reimbursed at 100 percent of the Standard Fee Schedules. The VBR Fee Schedule is applied to the relative value unit-based procedure codes and the time and base codes. The VBR Fee Schedule is applied only to Blue Cross commercial PPO. Keep in mind: Charges less than the BCBSM allowed amount will not receive the fee schedule uplift. Your practice’s charges may need to be increased to receive the full reimbursement. Just because you’re getting paid 100 percent of the BCBSM fee schedule does not mean there is not additional money you can earn if you achieve the top or second third of performers under this program. If you’re not currently part of a physician organization, or if your PO hasn’t nominated you for participation in PGIP, we can help! Give us a call at 517-486-4262 or visit us online for more information at...

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Check your 2018 MIPS participation status

Posted by on Apr 12, 2018 in Latest News | Comments Off on Check your 2018 MIPS participation status

Check your 2018 MIPS participation status

Physicians and other health care providers concerned about whether they are required to report under the Merit-based Incentive Payment System in 2018 can now check their status at qpp.cms.gov/participation-lookup. Don’t assume you’re required to report for 2018 just because you were included last year. CMS has raised the low-volume participation threshold to only include providers who receive at least $90,000 in Part B payments AND provide services to at least 200 Medicare patients (up from $30,000 and 100 in 2017). Falling below either one of those thresholds as an individual will exempt you from 2018 reporting and will ensure you receive no payment adjustment in the corresponding 2020 payment year. Additionally, keep in mind that CMS is currently basing this determination on payment data from the fall of 2016 to the fall of 2017. Another status check will be performed later this year to determine whether an individual’s Medicare volumes changed significantly from fall 2017 to fall 2018. Providers who were initially tagged to participate during the first determination period may be removed from participation at that time. However, no previously exempt providers can be added to the participation list during the second status check. Finally, don’t forget that these thresholds are applied at the group level for providers who elect to report through a registry or other group reporting methods. That means that even if you’re exempt as an individual, you will likely be required to report if your TIN elects to report as a group. If you have any questions about your participation, or are trying to decide whether group or individual reporting would be most beneficial, don’t hesitate to contact us by calling 517-486-4262, or by emailing...

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Vachette offering new service options for 2018

Posted by on Apr 6, 2018 in Latest News | Comments Off on Vachette offering new service options for 2018

Vachette offering new service options for 2018

Everyone knows Vachette specializes in billing audits and practice management, but we haven’t always done the best job communicating the other host of services we also provide. From employee productivity analyses, to helping you develop an effective sales and marketing strategy, you’ll be surprised at the variety of tasks Vachette can perform to ensure your lab or practice is performing at peak efficiency. Check out the full list below for a comprehensive breakdown of our services. Let us know if there’s something you had in mind that isn’t currently included — we’re always willing to discuss special projects on a case-by-case basis. Interested in learning more about any of our services? Call Vachette President Mick Raich directly at 866-407-0763 or email him at mraich@vachettepathology.com. Referring Physician comparisons Part A compensation strategy Part A / TC payback / Client bill strategy and negotiation Managed care strategy Billing costs analysis Billing process audits and benchmarking and KPI development Managed care payment authorization /analysis Fee Schedule comparison MUEs and LCD, review Credentialing analysis, certified credentialing specialist on staff MIPS and value plan assistance Revenue projections with CMS updates Year over year practice comparisons Hospital joint venture strategy and negotiation Merger and acquisition strategy Productivity analysis Pathology compensation strategy Part A RFP assistance Account payable and account billable services and auditing Bank reconciliation auditing Certified CPT coder on staff Compliance plan development and auditing Billing auditing, revenue auditing Managed care negotiations Revenue projections and amortization for new business lines or service areas Lab sales and marketing strategy Collection agency auditing and negotiation ACO / PHO negotiation Billing transition...

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Current Metrics in Medical Billing Contracts — White Paper

Posted by on Apr 4, 2018 in Latest News, White Papers | Comments Off on Current Metrics in Medical Billing Contracts — White Paper

Current Metrics in Medical Billing Contracts — White Paper

It’s no secret that as medical billing has become increasingly complex over the past decade, the contracts of third-party billers have followed suit. What used to be fairly standard agreements totaling a few pages have since evolved into lengthy documents littered with clauses that often seek to minimize the biller’s liability while also maximizing their profits. And while those should be the goals of any scrupulous business, that doesn’t necessarily mean there aren’t some billers who are squeezing their clients a bit harder than others. “There’s now a lot less risk in these contracts on the biller’s end,” says Mick Raich, President of Vachette Pathology. “It used to be if a biller screwed up, they’d pay for it. Now, they’re taking steps to limit their risks.” So, what steps should a medical group or practice be looking for when searching for an external partner to assist with their billing operations? Fortunately, Vachette has nearly 20 years of experience in helping our clients find and negotiate a contract with the biller who is right for them. We assist in every step of the process beginning with building a strong request for proposals, right up to signing on the dotted line. To offer a better idea of what specifically we look for when negotiating these agreements, this white paper will offer a blind comparison of six prominent billers throughout the United States. Download the full white paper for free by filling out the form...

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Analyzing the overhauled 14-day molecular billing rule

Posted by on Mar 12, 2018 in Latest News | Comments Off on Analyzing the overhauled 14-day molecular billing rule

Analyzing the overhauled 14-day molecular billing rule

Under the old CMS 14-Day Rule, reference and independent laboratories were barred from billing Medicare directly for molecular pathology tests ordered less than 14 days after an outpatient was discharged from the hospital. Besides the obvious administrative challenges this created for both labs and hospitals, there was also clinical concern voiced over potential delays in patient testing, access to test results, and implementation of treatment plans as the 14-day timeframe is accommodated. That changed recently when the agency published its Outpatient Prospective Payment System Final Rule for 2018. The new carve-out exceptions to the 14-day rule allows labs to bill Medicare directly under the Clinical Laboratory Fee Schedule for molecular pathology tests and advanced diagnostic laboratory tests that are excluded from OPPS packaging rules and ordered fewer than 14 days after a patient’s outpatient hospital discharge. If these criteria are met, the DOS for the excepted tests would be the date of testing rather than the date of specimen collection. The new rule went into effect with Jan. 1, 2018 date of service. This does not change the inpatient 14-day rule. The DOS is now the date the test was performed instead of the date the specimen was obtained if these conditions are met: The physician orders the test following the date of a hospital outpatient’s discharge from the hospital outpatient department. The specimen was collected from a hospital outpatient during an outpatient encounter. It would be medically inappropriate to have collected the sample from the hospital outpatient other than during the hospital outpatient encounter. The results of the test do not guide treatment provided during the hospital outpatient encounter. The test was reasonable and medically necessary for the treatment of an illness. Below is a full list of affected codes....

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