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Mr. Raich goes to Medicare

Posted by on Aug 25, 2016 in Latest News | Comments Off on Mr. Raich goes to Medicare

Mr. Raich goes to Medicare

Recently, I traveled to Baltimore to visit the Department of Health and Human Services Centers for Medicare and Medicaid Services.  This gave me a little insight into how things are playing out. During my 30 years in health care I have heard the word “change” many times. Now the current buzz words are “value versus volume” and “bundled payments”, phrases that are causing the latest round of mergers and acquisitions (M&A).  Instead of hospitals buying physician groups, it seems whole hospitals and health systems are merging. These changes are very evident in the CMS Department of Performance-Based Payment Policy Group the Division of Shared Saving Program the Division of Value-Based Payment. During my visit I learned CMS is a very busy place with more than 3,000 employees in one office building. They have others too, including many departments that all are trying very hard to move the quality of health care forward.  It is also a very large organization with tentacles in many different areas. My visit provided some great insight into what is happening in the bundled payment world.  For example, if you go to innovation.cms.gov, you’ll find the 75 different innovation models either in use or being proposed for use at this time.  The most interesting seems to be the Bundled Payment for Care Improvement Initiative, which allows you to see each bundle payment model that is currently being used.  It was interesting to note the current Oncology Care Model has 195 practices and is an Episode-Based Payment Initiative which looks at the patient’s age, gender and comorbidity, and pays a bonus to those practices that keep patients out of the emergency room and hospital.  This model took effect in July of 2016 and will be closely watched as a template for other models. What bundles will come next? The best guess would be to look for high frequency procedures with relative standardized episodes of care. For example, some Blue Cross Blue Shield plans are bundling endoscopies into a single payment by ambulatory care center. What’s in the crystal ball of health care changes for the next ten years?  My read is that there will be continued consolidation of health care until there are approximately 200 healthcare systems nationwide.  These systems would control utilization and quality in their region (remember, many of the new payment models are based on “regional” quality of care).  These regional players would then diffuse their government payments downward to their own providers. This model seems to fit the current financial situation.  Now no one at CMS will confirm this model and frankly they will be downstream of this change anyways. Bottom line from my visit:  We will have more bundled payments, we will have regional healthcare measurements and metrics and healthcare will continue to consolidate.  Until November at least, at which point all bets are off. But remember, The Department of Health and Human Services Centers for Medicare and Medicaid Services provide services for 100 million lives.  Medicare is the biggest insurance plan in the nation, so it’s no wonder politicians look at it and say, “Why not have Medicare for...

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Several pathology codes could see significant cuts under proposed Medicare fee schedule

Posted by on Jul 26, 2016 in Latest News | Comments Off on Several pathology codes could see significant cuts under proposed Medicare fee schedule

Several pathology codes could see significant cuts under proposed Medicare fee schedule

The Centers for Medicare and Medicaid Services has proposed rate cuts for a large number of TC pathology codes in its proposal for the agency’s 2017 Medicare Physician Fee Schedule, a move the agency has justified primarily as a reflection of the reduced cost of supplies for these procedures. The most significant proposed cuts would affect TC rates for 17 codes, with the most notable being a 15 percent reduction for 88305-TC ($29.34) that CMS has attributed to the decreased cost of utilizing eosin stain supplies rather than eosin solution. The other codes negatively affected by this adjustment include 88302, 88304, 88307, 88309, 88323, 88325, 88364, 88365, 88366, 88367, 88368, 88369, 88373, 88374, 88377 and G0416. The only other major reduction is a 19 percent drop for 88184, 88185 and 88189, which pertain to flow cytometry. Fortunately, the rates for professional components will remain largely unchanged. Although there were very few rate hikes proposed, there were at least some notable concessions made. The most significant hike would boost global reimbursement for 88361 by 4 percent ($155.98), while also upping the code’s technical component by 7 percent ($94.80) and its professional portion by 1 percent ($61.18). Additionally, the professional portion of the G0416 prostate biopsy would see a 17 percent boost ($184.96) Check out the chart below for a breakdown of the major proposed changes for several key pathology codes. Keep in mind that the conversion factor for 2016 is 35.8043, while the proposed factor for 2017 is 35.7751. Comparing these rate adjustments against your lab’s current volume will be essential in determining how your revenue stands to be impacted, assuming the proposed rates remain relatively static in the finalized Medicare fee schedule that is expected to be released in October. CMS is accepting public comment on its proposed fee schedule through Sept. 6. The new rates will then go into effect on Jan. 1, 2017. CPT Code Description Proposed 2017 Current 2016 Percent Change 88112-Global Cytopath cell enhance tech 68.33 72.32 -6% 88112-26 Cytopath cell enhance tech 28.98 29.00 0% 88112-TC Cytopath cell enhance tech 39.35 43.32 -9% 88184-TC only Flow cytometry/1st marker 61.53 76.26 -19% 88185-TC only Flow cytometry/each additional marker 37.56 46.55 -19% 88189-TC only Flow cytometry, read 16+ 92.30 114.22 -19% 88305-Global Tissue exam by pathologist 69.05 74.11 -7% 88305-26 Tissue exam by pathologist 39.71 39.74 0% 88305-TC Tissue exam by pathologist 29.34 34.37 -15% 88307-Global Level V, tissue exam by pathologist 269.03 312.21 -14% 88307-26 Level V, tissue exam by pathologist 87.65 87.36 0% 88307-TC Level V, tissue exam by pathologist 181.38 224.85 -19% 88312-Global Special stains, group 1 98.74 98.82 0% 88312-26 Special stains, group 1 28.26 28.29 0% 88312-TC Special stains, group 1 70.48 70.53 0% 88313-Global Special stains; group 2 70.12 69.10 1% 88313-26 Special stains; group 2 12.52 12.53 0% 88313-TC Special stains; group 2 57.60 56.57 2% 88341-Global Immunohistochemistry (Additonal stain) 90.15 90.23 0% 88341-26 Immunohistochemistry (Additonal stain) 28.26 27.93 1% 88341-TC Immunohistochemistry (Additonal stain) 61.89 62.30 -1% 88342-Global Immunohistochemistry (1st stain) 107.68 107.41 0% 88342-26 Immunohistochemistry (1st stain) 37.21 37.24 0% 88342-TC Immunohistochemistry (1st stain) 70.48 70.18 0% 88361-Global Tumor immunohistochem/computer 155.98 149.66 4% 88361-26 Tumor immunohistochem/computer 61.18 60.87 1% 88361-TC Tumor immunohistochem/computer 94.80 88.79 7% G0416-Global Prostate Biopsy 488.33 534.20 -9% G0416-26 Prostate Biopsy 184.96 157.90 17% G0416-TC...

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PAMA Final Rule: What to know and who it affects

Posted by on Jul 18, 2016 in Latest News | Comments Off on PAMA Final Rule: What to know and who it affects

PAMA Final Rule: What to know and who it affects

Late last month, CMS finally released the long awaited final ruling for the Protecting Access to Medicare Act of 2014 (PAMA), which implements largescale change to the process of establishing rates under Medicare’s fee schedule for clinical labs. The rule comes nine months after CMS first released its proposed PAMA ruling. Expect repricing under the rule to potentially have a significant impact on your revenue given that CMS has estimated Medicare Part B payments for clinical diagnostic lab tests will be lowered by $390 million during the 2018 fiscal year (and by a total of $3.9 billion during the subsequent 10 years). Some quick highlights: New reimbursement rates won’t take effect until Jan. 1, 2018 as opposed to Jan. 1, 2017 as initially proposed. The data collection period was reduced from one year to six months. Additionally, dates for data collection and submission were also amended. Labs do not need to report if they receive $12,500 or less in Medicare Clinical Laboratory Fee Schedule (MCLFS) revenue during the data collection period, down from the $50,000 reporting threshold put forth in the proposed rule. Advanced diagnostic lab tests (ADLTs) have been expanded to include protein-only tests. Additionally, the requirement calling for ADLTs to be performed at a single-lab facility has been removed. The definition of “applicable labs” will be based on a lab’s national provider identifier (NPI) rather than its taxpayer identification number (TNI). The change means some hospital outreach labs should now also have reporting obligations. Under PAMA, CMS will be required to update the MCLFS through rates paid by private payers for lab tests reported by “applicable laboratories.” The rates will be established by determining the weighted median of the reported rates, although the rate a test can be decreased each year will be limited. Since data collection for CDLTs is already underway, labs that stand to be affected by PAMA should be sure to have systems installed for collecting the required data, which they will be required to report to CMS during the first quarter of 2017. This means that labs that stand to be affected should already have a data-collection system in place in order to comply with the reporting requirement. Affected Laboratories In the final rule, CMS defines an applicable lab as one that bills Medicare Part B under its own NPI and collects more than 50 percent of its Medicare revenue during the data collection period under the MCLFS or Medicare Physician Fee Schedule and receives at least $12,500 in MCLFS revenue during the data collection period. The change came as a result of concerns that defining applicable labs based on TINs would exclude hospital outreach labs from reporting obligations and could in turn skew pricing due to the significant amount of Medicare Part B testing performed by those labs. The fear being that this would lead to lower reimbursement rates across the board. Despite this change, labs will still be technically report to CMS through their TIN. This means each unique corporate entity with its own TIN that operates a facility that meets the definition of an applicable lab must consolidate reports of its eligible labs into a single aggregated report. Timeline While the proposed rule called for the first data collection period to last for six months and for future collection periods...

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A quick look at the 2017 proposed Medicare Fee Schedule

Posted by on Jul 12, 2016 in Latest News | Comments Off on A quick look at the 2017 proposed Medicare Fee Schedule

The Centers for Medicare and Medicaid Services is aiming to better compensate primary care physicians for helping to coordinate their patient’s care and for providing behavioral health services, according to the agency’s proposed 2017 fee schedule that was released late last week. The latest proposal aims to raise payments for physicians assisting patients with care coordination and planning, care for cognitive disabilities and overall mental health care. Providers would also receive increased compensation for providing care to patients with mobility-related impairments due to the increased attention and time commitment these patients often require, which falls in line with the ongoing push toward value-based care being spurred by MACRA. While pathology labs and practices don’t stand to face any drastic changes most weren’t previously aware of, there are at least a few key items to note: The standard times established last year for six clinical labor services will remain the same. An additional 11 could also be standardized pending forthcoming recommendations from RUC. See the figure below. A number of CPT codes have also undergone slight work RVU modifications. Click here to see a full list starting on page 374. (Use the “ctrl F” search function on your keyboard to search for a specific code without scrolling.) Additionally, a couple key pathology-related proposals were also put forth by CMS as part of an effort to amend the hospital outpatient prospective payment system. A proposal to discontinue the use of the “L1” modifier on outpatient lab tests to identify unrelated tests on claims. These would instead be packaged if they appear on a claim with other hospital outpatient services. A proposal to expand lab packaging exclusion that currently applies to molecular tests to all lab tests designated as an ADLT that meet established criteria. CMS also noted that it believes some of these diagnostic tests that meet the criteria will not be molecular tests, but will also have a different pattern of clinical use than more conventional tests, which in turn may make them less tied to a primary service in the hospital outpatient setting than more common and routine lab tests that are packaged. An “A” status indicator would be assign to ADLTs once a test is designated an ADLT under the clinical laboratory fee schedule. Those pathology-specific adjustments aside, one of the most unique fee schedule proposals put forth is to expand the pilot Diabetes Prevention Program beginning Jan. 1, 2018. This would be the first time a preventative service program from CMS’ Innovation Center would be expanded into Medicare. CMS projects these moves will generate a substantial funding boost, according to acting administrator Andy Slavitt. “We conservatively estimate that these changes would result in approximately $900 million in additional funding in 2017 to physicians and practitioners providing these services,” Slavitt said on the CMS Blog. “Over time, if the practitioners qualified to provide these services were to fully provide these services to all eligible beneficiaries, the increase could be as much as $5 billion in additional funding for care coordination and patient-centered care.” CMS is also proposing to add a provision that would reduce outpatient prospective payment system spending by roughly $500 million in 2017 by no longer paying for services at an outpatient department at a higher rate. Besides physicians, the proposed fee schedule also pays nurse...

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Revenue changes for health care in 2016 … So far

Posted by on Jul 6, 2016 in Latest News, Videos | Comments Off on Revenue changes for health care in 2016 … So far

  If there’s one thing health care professionals can agree on, it’s that the shift to value-based medicine will significantly impact the way we do business in the very near future if it hasn’t already. Between new quality incentive programs, such as CMS’s Merit-Based Incentive Payment System, and the continued rush to consolidate within all parts of the industry, it can be difficult to keep track of how this cascade of changes not only affects your day-to-day operations, but also your revenue. Mick Raich, president of Vachette Pathology and Stark Medical Auditing and Consulting, has traveled throughout the country this year to various health care tradeshows and conferences to share his insight on how the health care industry’s ongoing transition to value-based medicine will impact your revenue stream, and more importantly, what you can do to prepare. During this Power Point presentation, Raich outlines several revenue-impacting changes the industry has faced so far in 2016, in addition to a few others that will take effect in the near future. (Note: Some subjects addressed in this recording, such as MIPS, were still in draft form at the time of the...

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Thanks for investing in me (Employee letter)

Posted by on Jun 22, 2016 in Latest News | Comments Off on Thanks for investing in me (Employee letter)

At Vachette Pathology and Stark Medical Auditing and Consulting, we believe it’s important to not only invest in our clients, but to invest in our personnel as well. That’s why we enroll each of our new team members in Leadership Management International’s Effective Personal Producivity program. The course not only helps increase productivity by teaching how to set and achieve clear goals for each day, but also helps employees become better overall communicators and team players. Below is a letter written by Cody Raich, executive data analyst for Vachette and Stark, after he recently completed the EPP course. Cody is the son of Mick Raich, founder and president of Vachette and Stark. Michelle Miller and Dad, In December, I started working at Vachette Pathology as a non-intern for the first time.  My ‘other’ Vachette duties have been trash man, landscaper, and cleaning crew. I always envisioned myself working at Vachette for a large part of my upbringing.  Seeing my dad attend tradeshows in his fancy suits and shiny shoes always made me envious and also proud.  (Then I grew up. Just kidding). I never really understood what Vachette actually did for a long time.  I never understood the world of medicine.  The HCFA’s, the co-pay’s, all of it, seemed so foreign to me.  Over the past few months, I’ve really started to hone in on the services that Vachette provides.  I’ve been able to see with my own eyes the kinds of value that we provide our clients.  We’re simply there for them.  They have a problem and before anyone, Vachette comes running. Back to me.  Starting out, I really wanted to get in on the services. I really wanted to be able to help our clients.  Basically, like every team, I want to be a starter, not a benchwarmer.  In order to start, I had to hone my skills. I hadn’t been on Excel before December for years.  The idea of me in a cubicle to myself sounded like an early introduction to my coffin.  I had grand plans of travel and exploration.  I wasn’t heading towards exploration, I wasn’t heading towards travel, I was heading towards a disaster.  So I got out. My dad has been saying for years that if I ever needed to get out, reset, and try anew, that I should contact him.  I reluctantly did that.  I’m crass to a fault, risky to a fault, stubborn to a fault, and certainly proud to a fault (I wonder where I got that from).  All those things are nice, but they don’t grow you up. Sometimes you have to put away pieces of yourself, and try to conjure up different things I know I have deep down, but was too afraid to retrieve. Things like hard work, dedication, loyalty, character.  Basically all the things that any young adult shouldn’t avoid but does out of fear. I have always been incredibly scared of starting my ‘career.’  I am afraid that if I attempt greatness and fall up short that I’ll never be able to be happy with myself as a failure of greatness.  I never wanted to be a champion of good; I wanted to be a conqueror of the extraordinary. Enrolling me in EPP meant a lot.  It means a lot to be invested in. ...

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Is your outdated fee schedule leaving money on the table?

Posted by on Jun 17, 2016 in Latest News | Comments Off on Is your outdated fee schedule leaving money on the table?

Problem: We recently conducted a billing audit for a hospital-based physician group that purchases the technical component from its hospital when performing outreach work. However, a review of the group’s charges for TC work showed the rates they were contractually obligated to pay back to the hospital (which was the basis for their fee schedule) were significantly lower than what Medicare allowed almost across the board. When totaled, the difference between the charged and the Medicare allowed amounts for these codes accounted for a $57,000 loss of revenue in 2015, money that would have otherwise gone in the physicians’ pockets. Process: Since the group isn’t in an anti-markup state, we were able to quickly bump their TC fee schedule up to 100 percent of Medicare’s allowable rate. But, because their rates were so much lower than Medicare’s — 22 percent or less in multiple instances — it’s possible the hospital was nearly receiving less than cost for the use of its equipment. So why wasn’t the fee schedule updated sooner? In this instance, it essentially comes down to a matter of complacency. The group had had always reimbursed its full TC payments to the hospital, which in turn hadn’t updated its fee schedule for quite some time. While the hospital will now undoubtedly want to raise its reimbursement rate in future contracts, the group will be able to pocket the difference between the two rates in the meantime. This serves as a perfect example of why it’s important to regularly compare your fee schedule against Medicare’s to ensure it is up to date and helping you to maximize your revenue. Have questions or concerns about your fee schedule? Click here to request a free review...

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AACC honors Vachette President Mick Raich with 2015 Outstanding Speaker Award

Posted by on Jun 9, 2016 in Latest News | Comments Off on AACC honors Vachette President Mick Raich with 2015 Outstanding Speaker Award

Vachette Pathology is pleased to announce our president Mick Raich has been awarded the American Association for Clinical Chemistry’s 2015 Outstanding Speaker Award. The award recognizes speakers who earned an evaluation rating of 4.5 or higher during a 2015 continuing education activity accredited by AACC. Raich, who received the award for his speech forecasting 2016 financial and clinical strategies for pathology practices, said he was honored to be selected as one of the recipients of the AACC award. “I’m honored and humbled to be presented with this award,” Raich said. “It truly is a testament to my years of hard work in the health care industry and it only further inspires me to continue my efforts as an educator and innovator in the field moving forward.” Raich has spent his entire 32-year career in health care. His experience began in direct patient care, bereavement counseling, and hospital management and progressed into pathology billing sales and management, pathology practice sales and marketing, revenue cycle management, and strategic consulting. Since founding Vachette in 2001, Raich has grown the company into a nationwide consulting and management firm that specializes in working with independent labs, hospital-based pathology practices, hospital and health systems, and university pathology groups. In 2013, Raich founded Stark Medical Auditing and Consulting to offer his services to specialties outside of pathology. Click here to view a full list of recipients of the AACC’s 2015 Outstanding Speaker...

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Theranos: The company transparency forgot

Posted by on Jun 2, 2016 in Latest News | Comments Off on Theranos: The company transparency forgot

Theranos: The company transparency forgot

By: Jacob Vugrinac, Director of Business Development Editor’s note: This article was originally published in late 2015, prior to official announcements that Theranos is being investigated by multiple federal agencies due to allegations that the company misled investors about the readiness and accuracy of its blood testing technology. Yesterday, Forbes re-estimated Theranos Founder Elizabeth Holmes’ net worth at $0 after having named her America’s richest self-made women last year with an estimated value of $4.5 billion. You won’t find Theranos in the dictionary.  And you won’t find it in a textbook on Mythology next to Dionysus and Zeus.  Where you will find it is on the front page of Forbes and Newsweek.  Theranos is actually not a word at all.  It is an amalgam of the two words that Elizabeth Holmes set out to revolutionize: therapy and diagnosis. As a 19-year-old sophomore at Stanford, Elizabeth Holmes decided that college was only holding her back.  Her work in the lab had produced what she believed to be a ground breaking technique in blood analysis.  She threw caution to the wind, dropped out of school and used money that her parents had saved for her education to found her very own company.  And so Theranos was born in the basement of her college home (In the basement of my college house we played beer pong and explored the fine line between a good time and alcohol poisoning.  We could have used Holmes’ help to know exactly where that line is.) Fast forward to the present day.  Holmes is the world’s youngest female billionaire and her once subterranean business is now a major player in Silicon Valley with an estimated worth of $9 billion.  You could say that dropping out was probably the right move.  Theranos is believed to be on the cutting edge of a paradigm shift in health care.  Theranos claims to be able to run hundreds of tests on a drop of blood far more quickly than could be done with whole vials and at a much cheaper price.  Theranos threatens to turn Pathology as we know it on its head. But we haven’t even touched on the most interesting part of this story.  Are you ready for this?  No one knows how they do it.  Only Colonel Sanders and his 11 herbs and spices are shrouded in more secrecy.  Theranos has attracted attention for both the ambition of its mission and the secrecy that veils its means of achieving it. Theranos has kept its billion dollar secret for ten years now due to a regulatory gray area.  Most labs perform their testing on equipment that they purchase from outside manufacturers.  Before these medical device companies are permitted to sell their equipment it must be approved by the FDA; this approval makes the validity and performance of the testing available to the public.  But Theranos makes their own equipment and because of this is not required to rely on the FDA for approval as long as they do not sell this equipment to any other labs.  Very clever Miss Holmes. Well surely there have been studies performed comparing the results of Theranos’ testing to the methodology currently used today?  When asked this question, Holmes brought up a study that she co-authored for Hematology Reports that showed a strong correlation between Theranos...

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Check your billing after a system upgrade!

Posted by on May 26, 2016 in Latest News | Comments Off on Check your billing after a system upgrade!

Check your billing after a system upgrade!

By: Angela Granlund, Executive Client Administrator We recently had a pathology group whose hospital upgraded its Laboratory Information System (LIS).  Initially, everything appeared to be working smoothly after the upgrade. However, while reviewing date of service procedure volumes a couple months later, I noticed that two of the CPT codes that the group normally performs had no volumes being shown as billed out. The group had not changed their testing capabilities, so I contacted their billing agency to find out why these two codes were not being billed. The billing company said they had not noticed the drop in volume or questioned it. After researching the issue, the biller found that the codes were no longer coming through the feed from the hospital. Upon further investigation with the hospital, they learned that when the hospital updated to the new version of the LIS, a glitch caused these two codes from the feed to the billing company. If this error had not been caught, it would have cost the group about $13,000 in revenue. But once the omission was identified, the hospital fixed the issue, created a file of the missing codes reaching back to the date of the LIS update and sent it over to the billing company, who then filed the claims.  Fortunately, the issue was identified soon enough that no denials for timely filing occurred. What do you need to do to make sure this doesn’t happen to you? Make sure you are in the loop when it comes to hospital or laboratory system updates or upgrades. Alert the billing staff or company when you know system changes are scheduled. Require your billing staff or company to track procedural volumes every month as well as review the data and question any variances. Do you get regular feedback from your biller? Are you confident that they haven’t missed billing anything for you?  If not, give us a call at 517-486-4262 – we can help you find...

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