$400,000 in limbo (Update)Last month, we detailed our work with a Florida-based pathology group who had roughly $400,000 in professional clinical pathology charges pending after a carrier began unexpectedly denying clinicals for the Medicaid products the company processes. After filing a complaint with the OCA, the carrier agreed to do a special project to reprocess the denied claims while they work on a fix moving forward.

vachettepathology.com

Who's Watching Your Wallet?

Mick Raich Monthly, June 2018

PAMA impact extends beyond CLFS • The Ohio and Missouri state Medicaid programs are using cuts to

the 2018 Medicare Clinical Laboratory Fee Schedule (CLFS) as thebasis for slashing their prices even further.

For starters, Ohio Medicaid reduced its fee-for-service lab test ratesto a maximum of 75 percent of the CLFS rates. Additionally,payment rates for clinicals, molecular work and other pathologyprocedures have been reduced by 5 percent!

Meanwhile, Missouri Medicaid (MO HealthNet Division) reducedits fee-for-service lab test rates to 80 percent of the CLFS!

These reductions come as a direct result of the private payer datalabs were required to report to CMS for the first time in 2017 underthe Protecting Access to Medicare Act. While many have contendedthe methodology for collecting the data was flawed since it primarilypulled from independent labs and excluded most hospital labs, theagency has largely responded with a shrug and an assertation that therates cannot be challenged by administrative or judicial review.

Looking at the numbers, it’s easy to see why CMS is digging its heelsin on this issue. The most recent projections estimate CLFSreductions will net CMS $670 million in savings in 2018 alone, andmore than $3.6 billion overall. Nearly 75 percent of the CLFS CPTcodes were decreased following the inaugural reporting period, whileonly 10 percent saw increases. Expect this trend to continue whenthe next reporting period rolls around in 2019.

Recent audit findings:

• Multiple accounts reviewed weremissing payments becausepayment forms were notsubmitted with the correctinformation until we identifiedthem. Our client's biller said theyhad also previously identifiedthese payments, but for somereason did not act to resolve theissue until after our audit!

• Four percent of the cases wereviewed in a recent audit had tobe re-billed after they were sentout incorrectly as professionalcharges. Fortunately, we identifiedthe mistake in time for the casesto be re-billed correctly as globalcharges!

• We discovered a handful ofmissing demo files during ourmost recent billing audit.Unfortunately, The cases were notbilled until after the audit becauseof the delay in working themissing files!

Follow Mick on LinkedIn, or visit his

blog at vachettepathology.com

for regular updates!

CMS reports vast majority of 2017 MIPS participants expected to avoid penalty

CMS recently announced that 91 percent of Merit-based Incentive Payment System (MIPS) eligible clinicians participated in the program in 2017 and avoided the 4 percent Medicare penalty that will be assessed next year.

With penalties rising over the next few years before being capped at a maximum of 9 percent for the 2020 reporting year, groups who continue to ignore this will only fall further behind the curve.

Those interested in checking their preliminary feedback may do so now by logging into qpp.cms.gov. Final performance scores are expected to be available July 1.

Salary contracts increasingly lean on KPIs, RVUs

As salaried pathologists are increasingly measured on productivity through key performance indicators and RVUs, we've handled a number of inquiries about how to best negotiate these contracts. Don't expect this trend to slow: a recent AMA study shows 32% of physicians have some compensation tied to productivity!

Carrier’s confusion over third-party policy causes improper denials

As labs across the nation continue to adjust to requirements of recently implemented prior-authorization programs (or laboratory benefit management programs, as they're also known), it appears the private payers partnering with these services are experiencing some confusion as well.

While conducting a recent billing audit for a South Carolina-based pathology group, we found several accounts that were allowed at less than the anticipated reimbursement amount. When reviewing these cases with our client’s biller, we determined the issue was stemming from an apparent limit on 88305 units.

In one instance, the group billed 13 units, but the carrier processed the allowed amount as only six units, according to the EOB. When questioned on this decision, the carrier responded by referencing a suggested policy from their prior-authorization partner stating prostate biopsies will be capped at six units to prevent fraud and abuse.

The issue? The carrier later clarified it had never officially adopted the policy, which means there should not have been denials related to it. However, the carrier was equally confused when it discovered that despite the 13 unites being submitted, only the six that were eventually paid were received by their system. The carrier was unable to explain what caused the number of units to be automatically reduced, but is now digging into the issue based on our discovery.

In total, we worked with our client’s biller to find 81 accounts that fell outside the expected allowed amount based on this issue.

While we expect to have clarification from the carrier soon, who knows how long this issue would have gone undetected had our client not engaged us to review their billing.

Private payers continuing shift toward value

Did you know that Aetna recently announced it expects value-based payments will comprise nearly 60 percent of all health care payments by 2020? What changes are you making to account for

this ongoing shift?

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!

Who manages your bank account?

While working to get a client's biller access to their account, we discovered no one in the group had access because their credentials had expired from inactivity!

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Looking to develop a website for your lab or

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Improper billing leads to massive settlement$1.65 million ... that's the amount a Vermont hospital recently agreed to pay after the U.S. Department of Justice alleged they knowingly submitted outpatient lab claims without the necessary documentation. And to think this came about because an employee turned whistle-blower after the hospital ignored her concerns over the improper arrangement.

"You have to be willing to get uncomfortable for change to happen."

As the industry continues to shift away from fee-for-service and increasingly embrace value-based payments, you must ask yourself what your group is doing to thrive in this new environment

Or are you simply doing what you have always done while your competition surpasses you?