Who's Watching Your Wallet? · LinkedIn, or visit his blog at vachettepathology.com for regular...
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Payments Imagine your group was par with a payer for several years until you one day learn two of your physicians are being paid at 60 percent of the CMS allowable rate without explanation. This was the reality one of our groups was facing after an amendment for the Medicare Advantage product was signed. When we got in touch with the payer, they admitted the pathologists had been attached to the wrong fee schedule. They're now reprocessing $32,000 in affected claims! vachettepathology.com Who's Watching Your Wallet? Mick Raich Monthly, Oct. 2018 Quick hits • OIG targeting lab tests for fraud: Curious as to why the OIG is now intensely reviewing the most frequently ordered lab tests for false claims and kickbacks? It's all about the revenue. For starters, the most recent round of CERT testing showed lab tests accounted for $1.12 billion in improper payments, while 2016 data from the OIG shows the top 25 lab tests comprised 63 percent of all Medicare payments for lab tests in 2016. In short, if you're frequently billing these tests (ie: metabolic panels, drug tests, genetic testing for colorectal and breast cancer, etc.) now is the time to ensure your house is in order. • 2017 MIPS scores re-adjusted: Be aware that your 2017 MIPS bonus adjustment for 2019 payments has likely dropped due to recent score reviews conducted by CMS. Because the program is budget neutral, new upward adjustments awarded to those who were incorrectly penalized have reduced previously awarded bonuses. While most reductions were very minor (generally around .2 percentage points or less), it's still a good idea to understand what your final adjustment is before the 2019 payment year begins. • CMS asking ACO participants to shoulder more risk: Heads up for those participating in the Medicare Shared Savings Program: CMS has proposed to limit the maximum time a participant can have no downside risk to two years for new members and one year for existing participants. The idea is to ensure all participants would incur at least three years of two-sided risk out of the five-year contract required to participate. While this change is yet to be set in stone, groups considering this track must realize CMS wants those reaping the saving benefits of this program to have more skin in the game. Recent audit findings: • While auditing 2017 dates of service for a client, we identified two claims that lacked documentation. When we followed up with the biller, they stated the cases had already been purged from their system! • We discovered a biller who was applying a 76 modifier when claims are denied for MUE and CCI edits, which resulted in the 76 modifier being denied by insurance companies due to an invalid modifier combo. The claims were then resent with 59 modifier and again denied as duplicates. Instead, the biller should use a 59 modifier initially to avoid the modifier denial and send corrected claims when changing 76 modifier to 59 to have the claim processed and avoid the duplicate denial. • Recently, we have found that some payers are pushing contracts with no AP codes listed. Watch out for this trend! Follow Mick on LinkedIn, or visit his blog at vachettepathology.com for regular updates!
Transcript of Who's Watching Your Wallet? · LinkedIn, or visit his blog at vachettepathology.com for regular...
PaymentsImagine your group was par with a payer for several years until you one day learn two of your physicians are being paid at 60 percent of the CMS allowable rate without explanation. This was the reality one of our groups was facing after an amendment for the Medicare Advantage product was signed. When we got in touch with the payer, they admitted the pathologists had been attached to the wrong fee schedule. They're now reprocessing $32,000 in affected claims!
vachettepathology.com
Who's Watching Your Wallet?
Mick Raich Monthly, Oct. 2018
Quick hits• OIG targeting lab tests for fraud: Curious as to why the OIG is now
intensely reviewing the most frequently ordered lab tests for false claims and kickbacks? It's all about the revenue. For starters, the most recent round of CERT testing showed lab tests accounted for $1.12 billion in improper payments, while 2016 data from the OIG shows the top 25 lab tests comprised 63 percent of all Medicare payments for lab tests in 2016. In short, if you're frequently billing these tests(ie: metabolic panels, drug tests, genetic testing for colorectal and breast cancer, etc.) now is the time to ensure your house is in order.
• 2017 MIPS scores re-adjusted: Be aware that your 2017 MIPS bonus adjustment for 2019 payments has likely dropped due to recent score reviews conducted by CMS. Because the program is budget neutral, new upward adjustments awarded to those who were incorrectly penalized have reduced previously awarded bonuses. While most reductions were very minor (generally around .2 percentage points or less), it's still a good idea to understand what your final adjustment is before the 2019 payment year begins.
• CMS asking ACO participants to shoulder more risk: Heads up for those participating in the Medicare Shared Savings Program: CMS has proposed to limit the maximum time a participant can have no downside risk to two years for new members and one year for existing participants. The idea is to ensure all participants would incur at least three years of two-sided risk out of the five-year contract required to participate. While this change is yet to be set in stone, groups considering this track must realize CMS wants those reaping the saving benefits of this program to have more skin in the game.
Recent audit findings:
• While auditing 2017 dates ofservice for a client, we identifiedtwo claims that lackeddocumentation. When wefollowed up with the biller, theystated the cases had already beenpurged from their system!
• We discovered a biller who wasapplying a 76 modifier whenclaims are denied for MUE andCCI edits, which resulted in the 76modifier being denied byinsurance companies due to aninvalid modifier combo. Theclaims were then resent with 59modifier and again denied asduplicates. Instead, the billershould use a 59 modifier initiallyto avoid the modifier denial andsend corrected claims whenchanging 76 modifier to 59 to havethe claim processed and avoid theduplicate denial.
• Recently, we have found that somepayers are pushing contracts withno AP codes listed. Watch out forthis trend!
Follow Mick on LinkedIn, or visit his
blog at vachettepathology.com
for regular updates!
New CLIA-waived testsThe CPT code, effective date and description for the latest tests approved by the FDA as waived tests under CLIA are below:
87651QW, May 2, 2018, Alere i Instrument (Alere i Strep A 2)
82274QW, G0328QW, May 4, 2018, McKesson Consult Immunochemical Fecal Occult Blood Test
80305QW, May 15, 2018, MyDrugTestCups.com, MyDrugTest Multi-Drug Urine Test Cup
80305QW, May 15, 2018, MyDrugTestCups.com, MyDrugTest Multi-Drug Urine Test Dip Card
80305QW, May 16, 2018, Confirm BioSciences, Smart Choice Multi Panel DOA Test Cup
80305QW, May 16, 2018, Confirm BioSciences, Smart Choice Multi Panel DOA Test Dip Card;
82044QW, 82570QW, June 14,2018, BTNX, Inc., Rapid Response U120S Urine Analyzer Test System (BTNX, Inc. Rapid Response Urinalysis Reagent Strips (Microablumin/Creatinine))
80305QW, July 16, 2018, Express Diagnostics International DrugCheck Multi Panel Drug Test Cups
80305QW, July 16, 2018, Express Diagnostics International DrugCheck Multi Panel Drug Test Dip Card
81003QW, July 27, 2018, BTNX, Inc., Rapid Response U120 Urine Analyzer Test System
80305QW, July 30, 2018, Hangzhou Clongene Biotech Co., ltd. Clungene Multi-Drug Test Easy Cup
80305QW, July 30, 2018, Hangzhou Clongene Biotech Co., ltd. Clungene Multi-Drug Test Dip Card
87502QW, August 10, 2018, Mesa Biotech Accula (Accula Flu A/Flu B test)
87502QW, August 10, 2018, Sekisui Inc., Silaris Dock (Silaris Influenza A&B Test)
Catch Vachette at these upcoming trade shows!
Look for the Vachette booth at these upcoming trade shows and conferences:
• College of AmericanPathologists CAP18:Oct. 20-24 at the HyattRegency in Chicago, Ill.
• G2 Lab Institute 2018:Oct. 24-26 in WashingtonD.C.
• Michigan Society ofPathologists FallConference:Dec. 1 at The Inn at St.John's in Plymouth, Mich.
Let us know if you're alsoplanning to attend any ofthese events and wouldlike to meet up!
CMS removing old quality feedback
reportsPQRS and QRUR feedback reports from 2016 and previous years will be removed from the online CMS portal at the end of the year, according to a recent announcement. Now is the time to pull this information and get it on file before it's too late!
At Vachette, we specialize in consulting and auditing for pathology practices.We have been working with hospitals, laboratories, and hospital-based groups for more than 15 years. Visit vachettepathology.com, call 517-486-4262, or contact Vachette President Mick Raich at 517-403-0763. Our experience and expertise are second to none!
Are you billing CP? Billing for clinical pathology is a
significant revenue stream that many groups have unfortunately given up on.
Curious about how you can turn this on? Just ask!New service
optionsSure, you know about our
audits and practice management services, but
what else can Vachette offer? Head to our website
to see our full list of services!
Medical Mutual exiting KentuckyMedical Mutual recently announced it will terminate its contract with providers in Kentucky at the end of the year. All claims submitted through Dec. 31, 2018 will be processed under the terms of the existing agreement. However, only those in Boone, Campbell and Kenton counties will remain in the SuperMed network as of Jan. 1, 2019.
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Our proprietary Billing Rating System takes a comprehensive look at each of the services your billing team should be performing for you, and then assesses how well they're doing in each of these areas. How would your biller stack up to the competition?
