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Better look closely at your billing. Why? We found a large commercial payer which is not paying according to contract.
Why would this matter if you are a professional provider billing under the CMS physician fee schedule? Well, take a look at the prostate biopsy code G0416. Per the carrier contract, the G0416 is to be paid at 125% of the insurance fee schedule; however, the carrier has been recognizing this G0416 under the contracted amount for “all other HCPCS codes,” which represents 70% of Medicare.
Is this costing you money? How are you going to handle this loss and renegotiate a fair payment?
According to the contract:
|G0416-G0418||125% of Carrier’s designated fee schedule|
|All other HCPCS codes||100% of Carrier’s designated fee schedule|
Does it seem you worked harder for less money in 2014? The answer may be found by reviewing claims submitted to new healthcare plans created by the Affordable Care Act. We did just that and found some very interesting shifts.
During the last part of 2014, some of our clients had fewer charge dollars going to traditional Medicaid, moving instead into new managed medical assistance and exchange plans. With this change, we have seen the collection percentage (payments divided by charges) decline compared to what traditional Medicaid had been paying.
One finding from our audit: If you are not contracted with a certain plan, your claims may be denied as “non-contracted” or “prior authorization required.” The necessary form to obtain authorization is available on the plan’s website, but as a pathologist, are you pre-authorizing lab services? Likely, the answer is no.
Take a look at the following 2014 year-end review we conducted for one of our groups. Beginning in June 2014, the shift began from traditional Medicaid claims into other non-state plans. Note the decreases in collection percentage for these other payers.
|Plan||Total Charges||Total Payments||Collection %|
Did your state move into government-sponsored managed medical assistance and exchange plans in 2014? Do you know what these plans are and if you are considered a participating provider? This review is well worth your while. You need to determine if your claims are being properly paid, and if you should be contracted with these individual exchange plans.
There are also issues with longevity; we have seen two of these Medicaid exchange plans go bankrupt already within the first year, leaving our groups with large losses.
Are you auditing this? How are you handling this problem? Do you know your direct losses?
Contact Vachette Pathology at 517-486-4262. We can help stop this loss and work with you or your biller to correct the problem.
Mick will be presenting at the upcoming G2 PathForward Symposium March 14, 2015:
The Path Forward for Pathologists and AP Labs: Developing a Business Plan for the Next Five Years
- Assess whether and when it makes sense to merge groups and labs
- Discuss strategies for negotiating with managed care providers and accountable care organizations
- Get insight into the importance of developing new revenue streams
To learn more and register go to labrevolution.com.
CMS has begun issuing notification letters to providers who are subject to the 2015 Physician Quality Reporting System (PQRS) payment adjustment penalty. This penalty is assessed to providers who do not satisfactorily report data on quality measures for covered professional services.
The letters were sent out the end of September, early October. The penalty of 1.5% applied to Medicare payments in 2015 will be issued based on the provider’s reporting in 2013.
Providers must note that the penalty will increase to 2% in 2016. If you are subject to the 1.5% penalty, it is imperative to ensure your processes for PQRS measures reporting are reviewed.
By Mick Raich, President
I’ve worked in the medical billing world for the past 20 years, both for billing companies and as the owner of an auditing firm. Never have I seen such rapid changes in the industry. Automation, outsourcing, and new workflow processes are driving these changes, with some billers struggling to keep up.
What can billing companies do to stay abreast of changes and shore up profit margins while retaining clients? Our new white paper looks at the current state of billing firms today, and then gazes through the looking glass at billing companies 10 years from now.
To download our white paper, please join our mailing list. We promise not to share your email or send you spam, and you can unsubscribe at any time.
Essentials for 2015 in Coding, Billing, and Collections for Clinical Labs and Pathology Groups
Thursday, December 4, 2014—Save the Date!
Are you prepared for the onslaught of coding, billing, and collection changes coming in 2015 relative to how Clinical Labs and Pathology Groups bill Medicare and private health insurers? Every lab that wants to do better at filing clean claims and getting faster payment must be prepared for these changes!
“It will be a high-stakes game in 2015 because both government and private payers are stacking the deck against clinical labs and pathology groups,” says Robert L. Michel, Editor-in-Chief of The Dark Report. “Across the nation, Medicare carriers and private health insurers are implementing myriad changes in coverage guidelines and reimbursement for both clinical lab tests and anatomic pathology services, in an effort to reduce their costs.
“There will be so many of these changes in how labs must code, bill, and collect during 2015 that, in a sense, the lab testing industry faces ‘financial death by a thousand cuts,’” continued Michel. “This makes it imperative that every lab’s billing and collections manager stay informed and be prepared for these changes.”
The good news: There’s still time to gear up for these changes! Get quickly up to speed on the specifics, and what you need to do to ensure fair and accurate payment in 2015 by taking advantage of this timely webinar, entitled “Essentials for 2015 in Coding, Billing, and Collections for Clinical Labs and Pathology Groups” on Thursday, December 4, 2014 at 1:00 PM EST.
Vice President of Commercialization Strategies, Consulting & Industry Affairs
President and Chief Operating Officer
APS Medical Billing
From the clinical lab side, we will tap the expertise of Rina Wolf from XIFIN. Rina is a nationally recognized expert in the field of laboratory reimbursement, and XIFIN is one of the nation’s largest companies providing revenue management and billing/collection services to labs.
For anatomic pathology practices, we’ll draw on the insights of Tom Scheanwald from APS Medical Billing, and Michelle Miller with Vachette Pathology, with decades of combined experience in compliant coding and effective billing for the pathology lab industry.
This panel of experts will present the essential changes coming in the clinical lab and anatomic pathology billing/coding/collection arena for 2015. They will discuss coming changes in Medicare, including the new final rules for the 2015 Medicare Physician fee update just published, as well as what is happening with private health insurers, ranging from UnitedHealthcare and Humana, to Blue Cross and Cigna, to name just a few.
What better or more timely forum for you to prepare your lab leadership and your billing/collection managers with the absolute most up-to-date information about how the Medicare program and private health insurers will change policies in 2015 policies that will make it even tougher for labs to submit claims and be paid on a timely basis.
Here’s just some of what you’ll learn during this
information-packed 90-minute webinar:
- Learn which Medicare program changes are likely to have the biggest impact on your Medicare billing and collections during 2015
- Understand the different ways that Medicare carriers will want your lab to submit claims during 2015, and how to best meet those requirements to ensure full and timely payment to your lab
- Know the specific new coding and billing requirements that will change at the nation’s largest health insurance companies during 2015
- Benefits of training your lab’s coding/billing/collections team in advance of January 1, 2015, to handle lab test claims in ways that meet the new Medicare and private payer requirements
- Discover overlooked secrets to generate a higher proportion of clean claims that payers reimburse at first submission
- How to reduce the average number of days that your lab’s claims go unpaid because your lab billing team is prepared for the changing requirements that take effect in 2015
- Gain insights into more requirements for lab test bundling by Medicare’s hospital outpatient prospective payment system (OPPS)
- Hear about specific changes in how payment for drug testing and pain management services will be handled during 2015
- Plus a live Q&A session to provide answers to your most pressing questions, and much more
THE DARK REPORT WEBINAR AT A GLANCE
DATE: Thursday, December 4, 2014
TIME: 1 PM EST; 12 Noon CST; 11 AM MST; 10 AM PST
PLACE: Your computer and/or speakerphone
COST: $195 per dial-in site (unlimited attendance per site) through 11/28/14, $245 thereafter
Vachette and Stark are committed to excellence, and part of that means education and continuous process improvement. Recently we sent some of our team to Effective Personal Productivity training. This entailed goal setting and time management. We received this testimonial from the leader:
“In my 30 years of leadership development and management training work, I’ve rarely come across a team whose members were so uniformly capable, articulate, hard-working, and purposeful while negotiating the challenging training experience we serve up to our clients.
For real success with this training (and, for us, that means not only improved business results, but also genuine behavior change), our participants have to make their training experience a top priority; their leaders have to give them strong support as they move through the learning process; and they have to apply their learning to real problems and opportunities and make things different and better.
Vachette / Stark gave us all that, and more. They created real synergy among themselves. Their combined learning effort brought about important organizational changes, changes that promise to help them stay in continuous improvement mode and to scale their company’s operations rapidly and effectively. It has been rewarding for me to be a part of these developments.”
— Bryce Harbaugh, Co-Owner, Midwest Management Systems, Toledo, OH.
I commend my team on a job well done; they will work hard to be diligent in using these new skills for both their own personal growth and the growth and management of our clients. I am lucky to have such strong, smart and caring people on my team.
By Jessica Jankowski, Executive Client Administrator
Once again we find another carrier creating a policy reflective of the Local Coverage Determination (LCD) that was published recently by WPS Medicare.
Medical Mutual of Ohio (MMO) created a policy effective July 2014 that tied the 88342 code to Lynch Syndrome tumor testing, thus requiring a prior authorization for any 88342 that comes through their door for processing.
While the 88342 is indeed one code that could be used in Lynch Syndrome testing, it is certainly not exclusive to this. Once these denials were detected, we promptly connected with a representative from MMO to review some of our claims, inclusive of pathology reports, so that they could see how these 88342 codes were being utilized.
Roughly a month later, they rescinded the policy. However, in order to get any claims paid, we needed to submit a “claims project” (fancy lingo for a spreadsheet with vital claim information) for MMO to reprocess the claims they originally denied. We were informed by MMO that this would be the only way to ensure payment on these claims (Medical Mutual , 2014).
1). Pay close attention to your denials. Is your biller providing you with detail of your denials monthly? This is a great way to spot any denial trends.
2). Be sure your biller can trace back all claims that were denied AND provide reporting on payment for these claims to ensure the process has been complete.
Medical Mutual (2014, June ). Retrieved July 2014, from Medcal Mutual Medical Policies: http://www.medmutual.com/provider/MedPolicies
Denials caused by missed update to the Skilled Nursing Facility (SNF) consolidated billing code edit lists
By Ann Lambrix
Executive Client Administrator
Yes folks, another issue with the G0461 and G0462 codes. Providers have seen denials for these codes stating “claim/service not covered by this payer/contractor. You must send the claim/service to the correct/payer contractor, indicating the charges should go through SNF consolidated billing.”
NOTE: Certain Healthcare Common Procedure Coding System (HCPCS) codes were not included in the 2014 annual update to the SNF consolidated billing code editing lists. A correction to the coding lists will be implemented in October, 2014. The affected HCPCS codes for practitioner billing are Q2050, (which will be added to File 1), and the professional component of G0461 and G0462 (which will be added to File 2). If you have claims with dates of service from January 1 through September 30, 2014, that have been erroneously denied, you should contact your Medicare Administrative Contractor to have the claims re-opened and re-processed.
Ann is the Executive Client Administrator at Vachette Pathology, your go-to source for auditing, practice management and industry updates and changes. Visit more of our news updates at vachettepathology.com/latest-news or call us at 517.486.4262.