Latest News

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. Will be implemented in Texas on March 1, 2017. Avalon Healthcare Solutions Partnered with Blue Cross Blue Shield of South Carolina and Blue Choice HealthPlan of South Carolina to implement a lab pre-authorization program. Requires labs who...

read more

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...

read more

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...

read more

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....

read more

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...

read more

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...

read more

MACRA Final Rule should ease providers’ fears for now

Posted by on Oct 17, 2016 in Latest News | Comments Off on MACRA Final Rule should ease providers’ fears for now

MACRA Final Rule should ease providers’ fears for now

By: Alex Mitchell, Practice Value and News Coordinator At long last, the Medicare CHIP and Reauthorization Act (MACRA) Final Rule has been released upon us, and lo and behold, the sky has not fallen. Our initial analysis shows that all the hand-wringing and apocalyptic proclamations were a bit overstated given that we now know providers who are currently engaged in some form of quality reporting will be able to easily avoid penalties to their Medicare reimbursements for the foreseeable future without being burdened with new reporting requirements. Quick Hits: The “Cost” category of the Merit-Based Incentive Payment System (MIPS) will not have an impact on a clinician’s MIPS score for the 2017 performance year. Pathways offering clinicians the opportunity to avoid Medicare penalties altogether in 2019 by reporting limited or full data sets during an abbreviated window in 2017 were finalized. The low-volume threshold at which clinicians are required to participate under MACRA was raised from $10,000 in annual Part B payments to $30,000 or 100 Medicare patients. More alternative payment models (APMs) are being reviewed by CMS in hopes of expanding the pool of “advanced” APMs that exempt clinicians from MIPS reporting. Perhaps the most important change CMS announced was its decision to finalize a proposal to offer multiple pathways that will allow providers to choose their own reporting pace and level of participation during the 2017 reporting year. Other changes from the proposed rule include the elimination of the “cost” category for the 2017 reporting year, the establishment of a higher threshold for low-volume providers to qualify for participation, and an expansion of what qualifies as an “advanced” alternative payment model under MACRA. Let’s breakdown the major changes: 2017 “Transitional” Year: Before we dig into the minutiae of the change put forth in the final rule, providers should be sure they fully understand just how low CMS has set the bar for satisfactory participation during MACRA’s inaugural year. Clinicians who will be fulfilling their MACRA requirements by participating in the Merit-Based Incentive Payment System will only need to report one quality measurement, one practice improvement activity or fulfill the requirements of the Advancing Care Information category in order to completely avoid a negative adjustment of up to 4 percent of their Medicare Part B reimbursements in 2019. This massive change from the proposed rule that was released in April partially came about as a result of the thousands of comments CMS received, many of which pointed out that a significant portion of MIPS-eligible providers wouldn’t be ready to fully participate next year. That being said, the minimal reporting requirement should only be considered by providers who have been ignoring the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM) and Electronic Hospital Record Meaningful Use (EHR MU) reporting to this point. CMS appears to have offered this route as a concession for these latecomers in hopes that they’ll become full participants in later years. The vast majority of providers who have already been engaged in some form of quality or cost reporting should instead consider either reporting during a reduced 90-day window in order to be eligible for a small Medicare boost in 2019, or attempt to report for the full 2017 calendar year in hopes of receiving a full 4 percent bonus (and possibly more if they...

read more

How pathologists can survive MIPS in 2017

Posted by on Sep 19, 2016 in Latest News | Comments Off on How pathologists can survive MIPS in 2017

How pathologists can survive MIPS in 2017

Is your practice still scrambling to get a handle on the ins and outs of the Merit-Based Incentive Payment System before it goes into effect Jan. 1? Well, take solace in knowing you’re not alone. In its current iteration, the proposed MIPS rule laid as part of the Medicare Access and CHIP Reauthorization Act (MACRA) was, simply put, not designed with pathology in mind. Under MACRA, physicians have the option to avoid MIPS participation by participating in various alternative payment models that the Centers for Medicare and Medicaid Services deems to be “advanced.” The bad news: Very few APMs currently qualify for participation and CMS won’t start accepting proposals for specialty-focused Physician-focused Payment Models (PFPM) until early 2017. This means eligible pathologists will be forced to at least partially participate in MIPS during the 2017 performance year, or risk facing future penalties to their Medicare reimbursements. Fortunately, the good folks at the College of American Pathologists are working to develop a pathology-focused alternative payment model that they hope will receive approval next year from CMS. Vachette has stayed on top of MIPS news throughout its development and has spent considerable time researching what the payment system will mean for pathologists, both in the short- and long-term. Here’s a breakdown of what you need to know: Performance Categories By now, you’ve likely read or heard at least some information on the four categories that will be measured to compile your total MIPS score. But here’s what you may not know: Pathologists will likely only be scored in two of the four categories, and possibly only one if you’re an independent lab. For a quick refresher, let’s run through the categories briefly and note how each ties to an existing quality measurement program.   Quality: At 50 percent of your total MIPS score, this category is the most heavily weighted among the four. It will act as the successor to the Physician Quality Reporting System, which is currently in its final performance year (PQRS penalties, meanwhile, will be levied through 2018). At the behest of CAP, CMS has stated it will allow pathologists use CAP’s eight quality reporting measures for 2017, however, there is no guarantee that will be the case in subsequent years. Those quality reporting categories include: Breast Cancer Resection Pathology Reporting Colorectal Cancer Resection Pathology Reporting Barrett’s Esophagus Pathology Reporting Radical Prostatectomy Pathology Reporting Evaluation of HER2 for Breast Cancer Patients Lung Cancer Reporting (biopsy/cytology specimens) Lung Cancer Reporting (resection specimens) Melanoma Reporting *IMPORTANT NOTE FOR INDEPENDENT LABS: The proposed rule appears to exclude independent labs from reporting quality metrics, however, CAP is still seeking clarification from CMS at this time. Under the proposed rule, eligible clinicians (EC) or groups that are exempt from a reporting category will have that category’s weight redistributed to the remaining categories. Resource Use: Weighted at 10 percent of an EC’s total MIPS score, resource use will replace the value-based payment modifier. As with VBM, pathologists will not face reporting requirements for resource use, since CMS calculates the category based on claims. Again, this category will be reweighted to zero and redistributed to remaining reporting categories. Advancing Care Information: This replacement for the existing EHR Meaningful Use program is slated to be worth 25 percent of an EC’s total MIPS score. But, (stop...

read more

PAMA Final Rule: What to know and who it affects

Posted by on Sep 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

In July, 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 came 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 to...

read more

Collection agency’s blunder leaves $565K in limbo

Posted by on Sep 7, 2016 in Latest News | Comments Off on Collection agency’s blunder leaves $565K in limbo

Collection agency’s blunder leaves $565K in limbo

A Midwestern pathology group we assist was recently being pushed by its third-party collection agency to pursue legal action for a number of unpaid accounts. Because of this discussion, we began receiving reports from the collection agency that were supposed to show the accounts the agency received each month from the group’s biller. However, as soon as we saw the account volume in the report, we knew something was off. A collection agency’s “error” led to them losing track of more than 3,400 worth roughly $565,000 during an eighth month period in 2016. The agency originally claimed they had not received these accounts until being confronted with proof that they indeed had. Since the pathology group’s biller was no longer responsible for the accounts once they were sent to collections, it’s clear there was very little oversight of the collection agency’s process. Although the report showed that only 114 accounts totaling about $15,000 had been sent over for collections from January to July of 2016, we knew that couldn’t be correct given that the agency had received 5,023 accounts from the group’s biller in 2015. When pressed, the collection agency said it hadn’t questioned the dramatic drop off in the volume of accounts they were receiving and instead blamed the biller by claiming they had loaded all accounts they were given. To debunk the collector’s claim, we worked with the group’s biller and their IT department to determine that during a three-month span from April to June of 2016, a total of 1,193 accounts were sent to the collection agency. Since the biller puts the accounts on a server that the collection agency must log into to download from, they were able to confirm through login records that the agency did in fact receive all the reports in question. When confronted with proof, the collection agency claimed the thousands of missing accounts were a result of an “error” on their end. They’ve since sent us and the pathology group a new report that shows they’ve received more than 3,500 accounts worth a total of $580,000 so far in 2016. Just a minor difference of more than 3,400 accounts and $565,000 from what they had originally reported. Needless to say, our group is now in the process of changing collection agencies. Who’s watching your revenue like this? Your biller won’t, since they write these accounts off (rightly so) as bad debt once they’re sent to collection. Even if your receiving reports from your collection agency, as our group was, it can be difficult to decipher them to determine if they’re working your accounts properly. That’s what we pride ourselves in at Vachette Pathology and Stark Medical Auditing: Finding the dollars that are slipping between the cracks! Give us a call today at 517-486-4262 if you’d like to talk with one of our team members about how our quarterly audits can help pad your...

read more