oig, ngs, pama, pgx and beyond
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DESCRIPTIONOIG, NGS, PAMA, PGX and Beyond. Rina Wolf VP Strategic Commercialization, Consulting & Industry Affairs Kyle Fetter VP of Advanced Diagnostics. Thoughts for our “Brave New World”. PAMA Timelines. - PowerPoint PPT Presentation
OIG, NGS, PAMA, PGX and Beyond
VP Strategic Commercialization, Consulting & Industry Affairs
VP of Advanced Diagnostics
Thoughts for our “Brave New World”
PAMA changes reimbursement for
first time in 30 years
New codes provide transparency – but
at what price?
Challenge to demonstrate our
value or continue to be “medical stepchild”
FDA again raises issue of LDT regulation
After enactment CMS will establish the process for temporary codes and unique identifiers (no date required)
January 1, 2015• Beginning on this date, Medicare administrative contractors may only issue a coverage policy with
respect to a test through a local coverage decision• CMS is precluded from making adjustments to payments for clinical tests based under regulations
previously promulgated under the “technological changes” adjustment authority
June 30, 2015 • Deadline for CMS to establish (through regulation) parameters for payment rate reporting
July 1, 2015 • Deadline for CMS to establish an expert outside advisory panel
January 1, 2016
• Applicable laboratories must begin reporting private payor payment rates
• CMS must assign an unique HCPCS code to existing Advanced Diagnostics that are paid under a miscellaneous code
January 1, 2017 • Market-based payment system and initial payment period for Advance Diagnostics is effective
October 1, 2018 • Deadline for GAO report to Congress
PAMA Unanswered questions
• Number of contractors – What criteria to determine and to select contractors?
• What is the make up of “advisory panel”?• Hospital labs/POLs – are these “applicable labs”?• Third definition of an Advanced Diagnostic– Do first three quarters start at
commercialization or coverage?• HCPCS codes• Industry beginning to be concerned about
long term pricing impact – seeing push for change
Energy and Commerce Committee’s 21st Century Cures Initiative
• Energy and Commerce Committee– Charged with how to move personalized medicine and medical
– FDA hearings• Sounds like they are recognizing legislation needed, rather than such
substantive change through guidance
• Options: create new framework, harmonize existing frameworks, one or the other
– Reimbursement• Understand we won’t have innovation if not paid for – but truly clueless as to
how to go about it
– Comments should be submitted now! - goal to produce white paper in early January
2015 code additions
• 22 NGS (Genomic Sequencing)and MAAA codes– Contractors instructed to Gapfill
– Will contractors price all or consider statutorily non-covered – some pre-natal and pediatric; contractors coming out against NGS coverage
– What happens to payment vs current method of billing for Tier I codes in NGS panels
• 60+ Not yet priced– Drug Class Screening, Definitive Drug Testing,Therapeutic Drug Assays
– CMS Recommendation: Delay in pricing.Rationale: These codes represent various drug screening codes, many of which are specific to individual drug testing. While we appreciate the recommendations for these tests, we areconcerned about the potential for overpayment when billing for each individual drug test rather than a single code that pays the same regardless of the number of drugs that are being tested for. Therefore, it is our recommendation to delay pricing for these codes at this time, until further information and education is obtained.
– “Super” codes?
2015 Final Rule OPPS/ASC
• CMS has finalized its proposal to package the technical component of select ancillary services, including many anatomic pathology services, into a single unified payment for services provided in hospital outpatient departments or free-standing ambulatory surgical centers (ASCs).
• Level I Pathology (APC 0342)
• 88304 (Level III – Surgical pathology, gross and microscopic examination)
• 88305 (Level IV – Surgical pathology, gross and microscopic examination)
• 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report)
• 88312 (Special stain for organisms)
• 88313 (Special stain for non-organisms)
• 88365 (FISH, per specimen; initial single probe stain procedure)
• Level II Pathology (APC 0433)
• 88307 (Level V – Surgical pathology, gross and microscopic examination)
• 88331 (Frozen section 1st block)
• 88342 (Immunohistochemistry) (Yes, this code is back-see below)
• 88120 (urine FISH, 3-5 probes, manual)
• 88121 (urine FISH, 3-5 probes, computer-assisted)
• 88360 (quant or semi-quant IHC, manual)
• 88361 (quant or semi-quant IHC, computer-assisted)
• 88184 (Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker)
• CMS also included APC 0345 (Level I Transfusion Laboratory Procedures), which contains a number of blood bank procedures.
• IHC G code – “killed” for 2015
– 88342 back
– two new IHC codes, 88341 and 88344. – 88341: Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain
procedure (list separately in addition to code for primary procedure)
– 88342: Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure
– 88344: Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure
• Prostate G Codes– G0416 – all prostate needle biopsies regardless of number, may be repriced for 2016
– 3 other recently introduced G codes deleted
• Fluorescent In-Situ Hybridization (FISH)– revised codes 88365, 88367 and 88368 to specify “each separately identifiable probe per
– It also created six new codes, three (88364, 88373, 88369) which apply to add-on FISH services and three (88366, 88374, 88377) which apply to multiplex probes.
• CMS established Relative Value Units (RVUs) that were lower than what was recommended by the American Medical Association/Specialty Society Relative (Value) Update Committee (RUC) for five of the none FISH codes.
Public Meeting: Advancing the Use of Biomarkers and Pharmacogenomics in Drug Development – 9-5-14
• No two companion diagnostics have been reviewed the same way
• NGS baffling:– How to handle new, and probably frequently added,
alleles to an already cleared panel– How to handle negatives– How to review rare populations– What should endpoints be?
• Is there a role for patient and physician reported outcomes?
FDA Guidance Released
• FDA stated will be opportunity for stakeholder comment and public meetings– 120 day comment period
– Proposed stakeholder meeting in January
– 11,000 labs may be performing LDTs – hundreds of thousands?
– http://www.regulations.gov/#!submit Comment;D=FDA-2011-D-0360-0002
• Have been trying to regulate since 1992 – can “substantive change” be done through guidance?
– Timeline:FG: NEW high risk LDTs must comply with premarket review.
– FG + 6 months: LDT labs must comply with listing requirements.
– FG + 6 months: Compliance with adverse event reporting requirements.
– FG + 12 months: FDA begins enforcement against existing (as opposed to only new) high risk LDTs.
– FG + 24 months: Publication of a priority list for [grandfathered] high risk LDTs.
– FG + 36 months: Begin enforcement of premarket review, especially to be: (A) Combination diagnostics (for drug prescription), (B) screening LDTs, (C) LDTs for certain infections and high risk uses including blood banking.
– FG + 4 years: Publication of a priority list for other LDTs, e.g. Class II moderate risk LDTs.
– FG + 5 years: Transition from Class III to Class II enforcement. The FDA specifically envisions “third party review” – CAP or NY State?
– FG + 9 years: End of transition to Class II enforcement.
Head Spinning News…• New WellPoint Program Will Reward Standardized Cancer Care
Regimens• In a significant new program, WellPoint Inc. will soon begin offering oncologists a
$350-per-month payment for each patient who is placed on one of the insurer's standardized cancer treatment regimens. The program is designed to curb rising cancer care costs, though some experts are concerned that it could discourage the advancement of personalized medicine by providing incentives for doctors to prescribe the same drug to large segments of cancer patients.
• American Society of Clinical Oncology Chief Medical Officer Richard Schilsky points out that programs like this one may push patients into the same treatment, while Yale Cancer Center Chief of Medical Oncology Roy Herbst said that while the WellPoint treatment recommendations are "reasonable," they were likely to limit the development of personalized medicine. WellPoint plans to roll out its program in six states beginning July 1. The Wall Street Journal
• Study Suggests Matching Lung Cancer Patients With Targeted Therapies May Improve Survival • Members of the Lung Cancer Mutation Consortium - led by Memorial Sloan
Kettering physicians - have reported data from more than 1,000 lung cancer patients tested for cancer driver mutations during a period of four years, finding a significant improvement in median survival among patients who received targeted therapy based on their molecular testing results compared to those who did not. Results were published May 20 in the Journal of the American Medical Association.
Competitive Environment or “If Johnny jumped off the bridge…”
• Labs are negotiating exclusive contracts with payors excluding specific competitors from their networks– Is this anti-trust violation?
• Difficulty in gaining provider status:– If proprietary, must first gain coverage
– If not, typically get “network full” response
• Need to plan for compliant out-of-network strategies for the long term
Real World, cont’d
• Considered false claim if provider has no intent of billing patient (that also makes payor responsibility $0)
• Payors visiting websites: eg UHC saw a statement on a lab website that indicated patients would only be held accountable for $100 for a $3500 test. Told lab they would only pay an out of network benefit of 60% of $100
• Recoupments of difference between capped pricing and what was actually paid
• Contractor audits:
– Palmetto GBA will collect an overpayment on all incorrectly paid code 81227 and 81355 services from dates of service 01/01/2013 through present.
• Follow the money - Management responsible for all actions, statements that result in $$ paid to lab – even if not by W2 employees
The Real World
• Commercial Payor Audits– “Pre-Pay” audits – verifying information
• As part of this process, we must review records for the patients on the enclosed claim list to verify adherence to standard billing practices. The records should include, but not be limited to, progress notes, laboratory, pathology and radiology reports and correspondence or any other supporting documentation for the services billed… Additionally, please provide the patient's intake form and documentation of the initial visit/consultation, regardless of the date range specified in the enclosed claim list.
– Verification that patient shares of cost were billed!• …submitting proof that our member paid their co-pays, coinsurance and/or
deductible for each of the claims…Acceptable proof of payment includes a cancelled check or a credit card receipt. If you did not collect the patient responsibility, please provide the reason why and any supporting documentation you have such as Financial Hardship documents.
– Go back a year or more
Lab Industry to Focus On Commercial Claims Processing Data
• Back end denials related to non-network coverage, medical necessity, frequency edits, additional information required, etc-– Up by 42% since 2011
• Average Patient Responsibility – Up by 36% since 2012
– Focus on: Patient Responsibility Workflow, Patient Portal
– Bad Debt on patient responsibility with standard billing practices is 29%
– Bad Debt on patient responsibility for those with capped patient out-of-pocket is 78% - risk not worth it!
• Increase in “100” reason-code denials: payments made to patient– Up by >180% since 2012
– Focus on: Automated Claim Status checking
– Bad Debt for those who have incorporated quick and aggressive patient follow up shouldn’t be higher than 15%
Compliance in the News…
• Labs Reassess Processing and Handling Payments in Light of OIG Special Fraud Alert
• Cigna Accuses Lab Co. Of $84M Billing Fraud– Cigna claimed that Richmond, Virginia-based HDL had engaged in an ongoing, fraudulent “fee-
forgiving” scheme that involves luring Cigna members to use the company’s health-testing services by telling them they don't have to pay for their share of the cost, then charging exorbitant reimbursement rates for thousands of claims to Cigna, violating the Employee Retirement Income Security Act and other federal and state laws.
“HDL has developed a business model designed to game the healthcare system by submitting grossly inflated, phantom ‘charges’ to Cigna that do not reflect the actual amount HDL bills patients,” the complaint said.
HDL touted to potential customers in brochures and flyers that they would have no responsibility to pay co-payments, co-insurance, deductibles or other costs for initial and follow-up testing by the company and that it would take on the risk of an insurance company not paying for the services, according to the complaint.
After attracting patients on health plans administered or insured by Cigna, HDL then misleadingly billed the plans unjustified “phantom” rates, including charges it had never collected or intended to collect from the patients, the complaint said. HDL often submitted charges to Cigna for reimbursement that were at least two to three times higher than Medicare rates for similar services, accroding to the insurer.
• Massachusetts lab agrees to $4.65 million settlement to resolve fraudulent billing claims to WV Medicaid, Medicare– Calloway Labs, headquartered in Woburn, provided clinical laboratory services, including urine
testing, for Medicare and WV Medicaid, but from March 2009 through April 2013 the company routinely billed both organizations using a code designated for pathology services in addition to the code for urine drug testing.
• Bostwick Laboratories settles whistleblower suit for $6.05 million– Allegations: Routinely (not on a case by case basis) perform fluorescent in-situ hybridization (FISH) testing on
atypical urine cytology cases regardless of whether the referring clinician requested FISH testing and then bills the government for the tests; and
• Perform other tests of dubious necessity without a physician order and also bills those to government payors; and
• Perform both the professional and technical components of FISH testing, but allow the referring physicians to bill for the professional component; and
• Charge referring physicians a reduced amount for the FISH technical component, which allows the referring physicians to mark up and bill Medicare for the full amount, and pocket the difference.
Frequent Issues Noted by Our Customers with Published Commercial Clinical Policies
• Payable indications per policies don’t match commonly used diagnostic codes:
• Aetna policy on Cyp2C19 covers patients who have been prescribed Clopidogrel, excludes 80% of the most commonly used diagnosis codes for patients treated with the drug
• Coverage indications are deliberately vague or difficult to prove, but ensure the need for additional information:– Testing “May be eligible for coverage if…” First Coast
– “The results of the… test will directly impact clinical decision-making AND clinical outcome for the individual.” Cigna
• OIG identifies questionable clinical laboratory billing in new study– Fifty-one percent of the 94,609 labs studied exceeded the allowed
threshold for at least one measure, and 1,032 (1.1%) had five or more measures that exceeded the allowed thresholds. (Most were POLs, but…)• The most frequently exceeded thresholds were for the following measures:
• High average allowed amounts per ordering physician
• High percentage of claims with ineligible ordering-physician numbers
• High percentage of claims with compromised beneficiary numbers
• High percentage of duplicate lab tests
• OIG Issues Special Fraud Alert on Specimen Processing and Registry Arrangements– The OIG has now highlighted two types of arrangements between labs
and physicians that it considers “suspect” under the AKS:• Specimen Processing Arrangements — payments by a lab to referring
physicians for collecting, processing and packaging specimens sent to the lab; and
• Registry Arrangements — payments by a lab to referring physicians for submitting patient data to a registry or database, for instance, as part of the lab’s R&D program.
CERT and Recovery Audit
• Collect documentation and perform reviews on a statistically-valid random sample of Medicare FFS claims to produce an annual improper payment rate.
• In 2012, CMS introduced the Recovery Audit Prepayment Review Demonstration, which allows Recovery Auditors to conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments. – The demonstration focuses on 11 states: California, Florida, Illinois,
Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas.
• Every $1 spent = $8-20 recovered!