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How to identify PQRS penalties

Posted by on Mar 13, 2017 in Latest News | Comments Off on How to identify PQRS penalties

How to identify PQRS penalties

Unlike other Medicare penalties, it’s not always apparent when a group is being penalized for PQRS. Do you know how to identify whether your group’s Medicare payments are being penalized because of prior poor performance under the Physician Quality Reporting System? You may assume identifying the 2 percent PQRS penalty is as simple as locating the PQRS remark code (N699) on your Medicare remittances and matching it up with a corresponding adjustment. Unfortunately, it’s a bit more complex than that. For whatever reason, CMS has elected to deduct the 2 percent penalty straight from your allowable amount, which means you won’t find a line adjustment that indicates your actual payment compared against the full allowable amount like you see with sequestration penalties. One biller we work with believed that since no adjustment was shown on the remittances, the PQRS remark code was simply a warning and not an indication of a reduction. Fortunately, we were able to use Medicare’s Fee Schedule Look-Up tool to show the payment the group received was actually 2 percent lower than the full allowable! So, other than understanding how the penalty was applied beforehand, what could the group and their biller have done to avoid this confusion? For starters, they could have paid attention when CMS informed them in the fourth quarter of 2016 that they had failed to satisfactorily report during the 2015 PQRS reporting period and would subsequently receive a 2 percent penalty on their 2017 Medicare payments (remember, PQRS penalties are applied two years after their corresponding performance year). However, we understand these communications can be missed, which is why we help our clients build reimbursement tracking or contract management reports that allow billers to quickly identify allowable amounts from various payers. By uploading your Medicare Fee Schedule, future payments you receive can be compared against your database to ensure you’re receiving your full payment. Remember, 2016 was the final PQRS performance year, which means 2018 will be the last time you could potentially see the 2 percent PQRS penalty. Unfortunately, penalties are only set to increase in subsequent years under the new Merit-based Incentive Payment System that combines PQRS with other quality and value reporting programs. This means those who have been ignoring quality reporting cannot afford to continue to do so. If you’re Medicare payments are down and your biller can’t explain why, or if you’re seeking an expert to assist you and your biller with new quality reporting requirements, call Vachette Pathology today at 517-486-4262 or visit us online at vachettepathology.com. We’d be happy to set up a free consultation with your group to outline exactly how we’ll ensure you avoid these penalties moving forward while also helping your practice locate money that has been slipping through the...

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Can your biller help you successfully navigate MIPS?

Posted by on Feb 23, 2017 in Latest News | Comments Off on Can your biller help you successfully navigate MIPS?

Can your biller help you successfully navigate MIPS?

With the inaugural reporting period for CMS’s new Merit-based Incentive Payment System now underway, you should be preparing a plan for how you’ll fulfill the program’s requirements, which can vary greatly depending on several factors ranging from the size of your practice to the number of patients you deal with directly each year. In recent years, many groups have relied on their billers to assist with reporting quality metrics required by the Physician Quality Reporting System. However, we’ve encountered numerous groups who have suffered Medicare penalties due to their biller’s failure to properly submit all the claims data required by PQRS. The reality is that although billers have good intentions, they often cannot keep up with the constant changes to these programs put forth by CMS. This has progressed to the point that many billers have now said they will either no longer assist with quality reporting or are charging additional fees to continue doing so. With that in mind, here are 22 items to consider as you prepare for MIPS: Are you confidant your biller truly understands the intricacies of the four MIPS performance categories: Quality, Practice Improvement, Advancing Care Information and Cost? Does your biller understand how those categories relate to the Physician Quality Reporting System (PQRS), Value Modifier (VM) and Electronic Health Record Meaningful Use (EHR MU) programs? Have you and your biller examined your Medicare payment history to determine whether or not you’re required to report under MIPS? Were you aware that CMS has dubbed 2017 as a “transition” year for MIPS? Have you and your biller had a conversation about what this entails, and what future years of the program could look like? Do you know whether you qualify for a MIPS exemption because of your hospital’s participation in a CMS-approved alternative payment model (APM)? Aware you aware of the potential benefits, as well as the risks, of participating in these various APMs? Have you received PQRS or Value Modifier penalties in the past? Was your biller able to explain why you came up short? If you did receive Medicare penalties under previous programs, did your biller offer to assist you with the appeal process? Was the appeal successful? Are you aware of whether you meet CMS’s designation as a non-patient facing clinician under MIPS? You should understand both the threshold for this designation and its potential impact on the categories you’ll be required to report on. Do you understand the differences between quality reporting under PQRS and the new Quality category of MIPS? How intimately does your biller understand the various quality measure groups of the Quality category? Can they help you determine which measures are applicable to your group, and how many you must report on to achieve your full score? Does your biller know the MIPS scoring thresholds that could open your group to receive additional Medicare bonuses beyond the maximum 4 percent initially offered for 2019? Has your biller determined whether or not your group will be required to report in the Advancing Care Information category? Do they understand how a category’s weight is redistributed if you receive an exemption? Have they discussed what Practice Improvement activities among the more than 90 available options would best suit your group. Have they supplied you with a plan for how to best...

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Understanding the benefits of registry reporting

Posted by on Feb 20, 2017 in Latest News | Comments Off on Understanding the benefits of registry reporting

Understanding the benefits of registry reporting

Understanding Registries With the first reporting period for the Merit-based Incentive Payment System now underway, you’re probably already spent some time considering how you’ll report your quality data (and if you haven’t, now’s the time to start)! Most groups fulfilled their PQRS requirements in the past by submitting data through the routine Medicare claims process, however, that process has become more burdensome in recent years and can leave you with uncertainties over whether you’ve reported all the applicable data required. What is a reporting registry? The registries referred to in this article were created to assist physicians in reporting quality data to CMS as part of the old Physician Quality Reporting System. Instead of placing the entire reporting burden on an individual group or practice, registries allow groups to submit their data to a third-party vendor that can scrub the submission to ensure it’s as accurate as possible before being sent off to CMS. This process aims to provide users with feedback that can help them fix their reporting processes during a submission period as opposed to waiting more than a year and a half for CMS to provide feedback on your data. Why use a registry? Working with a registry greatly reduces the burden on your billing and reporting staff. The registry staff can provide guidance with compiling necessary data. The registry can send in test submissions, which in turn allow them to minimize issues during the actual submission period. What’s the cost? Typically around $300 per physician. How are they approved by CMS? In order for an entity to be considered a qualified registry, the registry must successfully complete the self-nomination process and follow requirements outlined by CMS each year. Individual physicians or group practices who wish to report via registry should review the 2017 Qualified Registries once it is released this spring to find a registry that best meets the practice’s needs, since the vendor may only support specific measures or reporting options. (Click here to view the 2016 list of approved registries.) Who is able to report through a qualified registry? For the initial 2017 MIPS reporting year, both individuals and group practices can report through a qualified registry. Unlike past years, those wishing to report as a group will not need to complete the Group Practice Reporting Option registration in order to be recognized as a reporting group. Instead, those groups will now be able to self-nominate as a group through their registry. This is also the first year that groups will be prevented from submitting their quality data through the Medicare claims...

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Pathology Charges, Payments and Salary Trends in 2016 — White Paper

Posted by on Jan 14, 2017 in Latest News, White Papers | Comments Off on Pathology Charges, Payments and Salary Trends in 2016 — White Paper

Pathology Charges, Payments and Salary Trends in 2016 — White Paper

This white paper will look at pathology charges, payments and salary trends as of December 2016. I have done this review several times throughout the past 14 years of my career to shine a spotlight on the “real” compensation of pathologists. Our data comes from private practice pathologists, not from academic centers or salaried groups. We received assistance with the data collection process from several billing firms, including Physicians Professional Management Corporation of Lewiston, Maine; APS Medical Billing of Toledo, Ohio and several other sources. Many other billers were contacted with a request to help us gather data, however, they all declined. We also used data from more than 95 pathology practices in the 2016 Vachette Pathology database. In total, our study looked at the compensation of more than 550 pathologists in 2016. This study also examines Medical Director and Part A compensation, anatomic pathology billing and collections, clinical pathology billing and collections and independent laboratory billing and collections. Your Name (required) Your Email...

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Commercial insurers aim to lower lab reimbursements with pre-authorization programs

Posted by on Jan 12, 2017 in Latest News | Comments Off on Commercial insurers aim to lower lab reimbursements with pre-authorization programs

Commercial insurers aim to lower lab reimbursements with pre-authorization programs

Laboratory pre-authorization or “management” programs are controversial models that have gained prominence in recent years after being implemented in Florida by UnitedHealthcare in Oct. 2014 as part of a partnership with Beacon Laboratory Benefit Solutions (a subsidiary of LabCorp). The primary goal of these programs is to ensure health care providers within a particular state only use labs within a carrier’s “choice network” when ordering certain outpatient lab services for members of that network. Under these rules, the use of out-of-network labs is not permitted. These programs have been largely opposed by physicians in states where they’ve been put into effect, given that these doctors believe this practice causes unnecessary delays for patient treatment, and creates unnecessary obstacles for physicians ordering tests. Some doctors also believe these hurdles damage longstanding clinical relationships between physicians and their preferred labs. It also means that patients who may have been frequenting their doctor’s preferred labs now have to go to one of a handful of in-network labs. Receiving a “lab of choice” designation under these programs typically depends on meeting certain “quality” standards (e.g., CAP or TJC Accreditation, secondary pathology reviews or sub-specialty credentials) and “efficiency” standards. Under UHC’s program, standards include accepting UHC payments in the lowest quartile for the lab’s place of service classification (independent lab, outpatient hospital lab, or physician office lab). Since Beacon’s implementation in Florida, a couple commercial carriers in other states have followed suit and implemented their own authorization lab programs. Although they don’t all function in the exact same fashion, they each serve the purpose of funneling work to carriers’ preferred labs while alienating labs that choose not to play ball. Let’s take a quick look at some of the major players. Beacon Laboratory Benefit Solutions (LBS) Pre-authorization program first implemented as a pilot in Oct. 2014. Under the program, physicians serving UHC’s commercial patients in Florida must notify UHC when ordering any of 80 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 has been largely opposed by Florida physicians, who believe it causes unnecessary delays for patient treatment, and create unnecessary obstacles for physicians ordering tests. An in-network lab that is not a “Lab of Choice” may be chosen by the ordering physician, but Beacon’s system creates barriers to this selection. The physician must navigate to another screen and will be presented alerts warning that “reimbursement may be impacted.” The program does not allow use of out-of-network laboratories. 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. UHC expects laboratories to enforce compliance by pressuring referring physicians to complete the notification process when required. Anecdotal evidence from Florida indicates referring physicians are frequently non-compliant, and that laboratories are simply not being paid for testing performed on UHC patients in those cases UHC is Florida’s second largest health insurer with approximately a 14 percent share of the market. Was originally slate to be implemented in Texas on March 1, 2017, however, pushback from various physician groups has delayed that implementation indefinitely. Avalon Healthcare Solutions Partnered with Blue Cross Blue Shield of South Carolina and Blue Choice...

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Examining the differences between PQRS and MIPS

Posted by on Jan 6, 2017 in Latest News | Comments Off on Examining the differences between PQRS and MIPS

Examining the differences between PQRS and MIPS

2017 is here, which means the inaugural reporting period for CMS’s new Merit-based Incentive Payment System (MIPS) is now in effect. You’ve probably heard that reporting quality measurements under MIPS will follow a format similar to what was required under the old Physician Quality Reporting System (PQRS), but may not be aware of the exact differences between the two programs. Fortunately, we’ve compiled a chart that can be used as a visual to quickly understand the major differences created by this transition. If you have any additional questions about the specifics of either program or want to know more about how you can successfully report quality measurements this year to avoid a Medicare penalty in 2019, feel free to contact us by calling 517-486-4262. We’ve assisted numerous groups throughout the nation by helping them create a game plan to succeed with MIPS reporting and would gladly discuss how we could do the same for your...

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Looking for a registry to assist with MIPS? Check out the full CMS list!

Posted by on Dec 8, 2016 in Latest News | Comments Off on Looking for a registry to assist with MIPS? Check out the full CMS list!

Looking for a registry to assist with MIPS? Check out the full CMS list!

With the new year on the horizon, physicians should be preparing to report their quality and value metrics through the new Merit-based Incentive Payment System if they’re not participating in an Advanced Alternative Payment Model that exempts them from the Medicare reimbursement program. While many individual physicians and groups were able to survive the Physician Quality Reporting System through claims-based reporting, the expected elimination of that reporting method after 2017 means groups should be considering their options to get on board with a registry that can assist with MIPS reporting. Click here to view the full list of registries CMS approved for 2016 quality reporting. CMS-approved registries collect clinical data from a clinician or group practice and submit it to CMS on behalf of MIPS participants. Unlike claims-based reporting, which essentially sets a reported measure in stone once an applicable claim is submitted to CMS, registries can provide ongoing feedback on your reporting before it’s finalized to help ensure you’ve reported to the best of your ability, as opposed to waiting for CMS to provide feedback on your work more than a year after it’s been submitted. Although these registries must still reapply for certification from CMS for 2017, it’s best to start considering your options now so you’re ready to hit the ground running once your preferred choice is approved for participation early next year. Typically, we’ve seen these registries cost groups about $300 per reporting physician. However, we strongly suggest you attempt to negotiate a better rate if you’re part of a large group. While there are numerous registry options available, you’ll want to be sure you only consider registries that support the quality measure groups or individual measures that are applicable to your practice. We’ve already guided numerous clients through this process and are happy to provide assistance to anyone else seeking to make the transition to a registry. Keep in mind that Vachette also offers additional guidance that can help you or your practice work through the numerous changes to value metrics. For the cost of a few specimens per month, we will ensure you do not lose any money during the transition from PQRS to MIPS. Contact our office at 517-486-4262 today so we can help you get...

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Best practices for approaching payer audits

Posted by on Nov 3, 2016 in Latest News | Comments Off on Best practices for approaching payer audits

Best practices for approaching payer audits

As we continue to see an increasing number of payer audits in the pathology world, we wanted to take the time to walk you through some best practices and helpful tips for navigating these audits and protecting your revenue. It’s important to note that these audits will not be limited strictly to Medicare. Many managed care organizations have identified this as potential cost savings and now have their own internal audit teams or have hired third party auditors to validate your charges. Sometimes, these requests may not be directly addressed as an audit and may instead come in another form. It is imperative that you or your biller are on the lookout for these types of communication (or denials). Some auditors are finding 100% error rates – and may go back years to reprocess and take back payments already made to you. You must be vigilant in understanding your contract and the payer’s limitations on takebacks. We’ve seen clients successfully win money back because, under their contract, the payer could only recoup back “x” number of months or years. Unfortunately, many billers are still appealing these incorrectly because they are not communicating these denials and getting the coding department or doctors involved to write these appeals! Several of our groups that bill stains are having issues with limitations of units, medical necessity denials and back end audits.  The billers are often not staffed well enough to have a successful appeal process, which many of these carriers are banking on to begin with! These payers are looking for signed requisitions for IHC/special stains/molecular orders and/or documentation of medical necessity. Action steps for appeals: Include in the pathology report the trigger words:  “ X was ordered because…”. The auditors are most likely not pathologists, they usually just look for trigger words. When an audit request is received, it’s not enough to just send the final reports. Also, include an additional signed attestation by the pathologists that they ordered such and such stains/flow/ihc/molecular. Include a copy of relevant medical chart notes that makes it clear why the pathology specimen was ordered in the first place, i.e. surgeon’s note saying a colectomy was indicated due to presence of cancer or obstruction....

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Navigating MUEs

Posted by on Nov 3, 2016 in Latest News | Comments Off on Navigating MUEs

As with most CMS initiatives, it can be difficult to keep pace with the constantly evolving list of medically unlikely edits, especially when considering CMS and other carriers reserve the right to maintain a list of unpublished MUEs that providers and their billers likely won’t know about until they receive a denial. We were first gifted with these edits when CMS implemented an unpublished MUE list in 2007 with hopes of reducing the error rate of paid claims. Fortunately, the agency decided to begin publicly publishing most MUEs in October 2008, and now updates the list quarterly. In an attempt to highlight the constantly evolving nature of MUEs, we’ve identified changes to the maximum number of allowed units for some of the most popular pathology codes that occurred between the list published by CMS in July 2015 and the most recent one released in October 2016. It’s worth reiterating that CMS and other carriers reserve the right to create unpublished MUEs, which means CMS’s published list is really more of a national guideline than a hard and fast rule. However, an MUEs existence doesn’t prevent you from appealing to potentially receive full payment for all services provided. We work closely with our clients and their billers to make sure billers are appealing MUE denials and that our clients are getting paid on those appeals. But just because a denial is appealed doesn’t necessarily mean you’re going to get paid, especially if the physician’s documentation does not clearly substantiate the necessity of the number of units performed. We have encountered some billers who just want to just slap on a 59 modifier to override the edit, but we’re finding more and more that these MUE edits are often not overridden with a 59 edit. You must support those numbers with sufficient documentation if they exceed the limit. We’ve also seen billers who change the number of units to get around an MUE. Their argument is that the carrier will deny 100 percent of the charges otherwise, so they attempt to get paid on the maximum number of allowed units rather than none. That’s a major red flag in terms of compliance that could create headaches down the road later if you’re audited. While we know many billers don’t want to dedicate the time and resources necessary for an appeal, they need to understand they must bill only what was performed. And if the carrier denies it, they have to go through the appeal process. It’s best to get a handle on that process now if you haven’t already so that you’re not left scrambling down the...

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Want to avoid Medicare penalties under MACRA?

Posted by on Nov 3, 2016 in Latest News | Comments Off on Want to avoid Medicare penalties under MACRA?

Want to avoid Medicare penalties under MACRA?

Sure you do. And we can help. Unless you’ve been living under a rock (or avoiding revenue issues like the plague) chances are you’ve heard the Centers for Medicare and Medicaid Services released the Medicare CHIP and Reauthorization Act (MACRA) Final Rule upon the masses in mid-October. But what does that really mean in terms of how your practice’s Medicare Part B revenue stands to be impacted? We’ve covered seemingly every aspect of MACRA and the Merit-based Incentive Payment System since its passage in 2015 and numerous iterations along the way. And we’ve broken down the system’s various components at length, including taking looks at the varying reporting obligations specialty clinicians face as opposed to their primary care counterparts. This paper, conversely, is intended to provide a brief overview of the action steps most pathologists can take to avoid a penalty to their 2019 Medicare reimbursements based on their MIPS performance next year. MORE: Read our breakdown of the major changes put forth in the final rule. Understand that this won’t answer all your questions if you’re just jumping into the game. But rest assured, we’ve done the research and have answers to nearly any scenario you can think of. Give us a call at 517-486-4262 or email amitchell@vachettepathology.com and we’ll be happy to look into your unique situation. Is there a way I can avoid MIPS? Do you or your group receive less than $30,000 in Medicare Part B payments and see fewer than 100 Medicare patients each year? Are you participating in an Advanced Alternative Payment Model (APM)? Are you a first time Medicare enrollee? Unless you answered “yes” to any of these questions, then you’re most likely stuck going along for the ride. What qualifies an APM as “advanced”? CMS has identified a handful of APMs that use certified EHR technology, feature payments tied to quality metrics similar to those measured by MIPS and require participants to bear some financial risk for reimbursement. In order to avoid MIPS reporting, a clinicians must receive at least 25 percent of their Medicare Part B payments through an advanced APM or see at least 20 percent of their Medicare patients through the model. Those who meet this requirement during the 2017 performance year will automatically receive a 5 percent lump sum incentive payment in 2019. Eventually, participants under this track will also receive a higher annual fee schedule increase. Below is a list of APMs that will qualify for the 2017 performance year: Track 2 and Track 3 Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) Pioneer ACOs NextGen ACOs Oncology Care Model two-sided risk arrangements Comprehensive Primary Care Plus Comprehensive ESRD Care What if I participate in an APM that’s not on this list? If you participate in an APM that’s not on the advanced list, or if you don’t receive enough Medicare payments through the model to meet the participant threshold (noted above), you will be required to report under MIPS, but will likely have a reduced reporting burden. Also, CMS expects to add more APMs to the advanced list each year, so there’s a good chance your model might receive the designation in future years. We’ll be happy to let you know what your requirements for 2017 are if you feel this situation applies to...

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