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.
A payer recently dropped their payments 30%! There was no reason given. We sent a termination letter…there was no reason given. Why accept a 30% pay cut from a publicly traded company that makes a 5% margin each year? Where is our 5% growth? Come-on! Negotiate a better living!