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Who's Watching Your Wallet?

Mick Raich Monthly, August 2018

CMS may expand PAMA scope As CMS continues to defend rate reductions to the Clinical Laboratory Fee Schedule triggered by the required reporting of private payer rates under the Protecting Access to Medicare Act, the agency has signaled it may be rethinking its methodology as it is now soliciting comments on whether it should expand the scope of laboratories required to report. While initial the narrow definition of an “applicable laboratory” resulted in pricing data being overwhelmingly gathered from national labs, CMS is now asking whether hospital outreach and physician office labs should also be included, a move advocates believe would result in more favorable pricing data being included.

During the inaugural reporting period in 2017, CMS only required data from labs who received more than 50 percent of their Medicare revenue from the CLFS under their own NPI, an exclusion that left hospital labs billing under their hospital’s NPI on the outside. Now, CMS is considering allowing labs to use a CMS-1450 bill type 14x or CLIA certificate numbers to determine whether or not they are an applicable lab.

The next data collection period for private payer data will run from Jan. 1, 2019 to June 30, 2019. Labs will then be required to report that data between Jan. 1 and March 31, 2020. CMS is expected to announce any reporting changes with the release of the 2019 MPFS Final Rule this fall.

BCBS of MI raises stakes for PGIPThe withhold amount for the BCBS of MI Physician Group Incentive

Program changed from a 5 percent to a 7 percent allocation as of July 1. That means even if you're earning 100 percent of the standard fee

schedule, you're still losing 7 percent up front! To offset the change, the PPO conversion factors received a 2 percent bump.

Recent audit findings:

• We discovered one private payer inNew Jersey is denying 88342s as aservice not provided by thenetwork. However, we determinedother clients in the area are eithergetting paid without denials or arebeing paid after appeal. We're nowworking to bring this inconsistencydirectly to the payer.

• During a recent audit, we foundour client's charge master forG0402 was less than Medicare iswilling to pay. Unfortunately, thisresulted in a loss of $15.78 everytime that charge was billed toMedicare.

• Despite identifying eight cases thatrequired action to be paid correctlyin a recent billing audit, we laterlearned the biller chose not toresolve the issues we raised untilwell after our review wascompleted! Unfortunately, theirinaction tied up thousands ofdollars in revenue in the meantime.

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for regular updates!

CMS proposes to increase TC rates for key pathology services in 2019 Medicare Physician Fee Schedule Proposed Rule

CMS released its Proposed 2019 Medicare Physician Fee Schedule in July and unveiled a host of payment bumps for the technical components of several key pathology codes.

The agency proposed a roughly 8.5 percent hike for 88305-TC, which would see the payment jump to $32.81, while the code’s global rate is proposed to see a 2.7 percent increase to $72.09. However, a 1.7 percent reduction was proposed for the professional interpretation -- dropping the payment to $39.29 -- a move that largely foreshadowed CMS’s decision to slightly cut professional rates while boosting technical and global components for many major pathology codes.

The most significant cuts will again impact prostate biopsies, with the technical rate for G0416 being hit the hardest by a proposed 18.9 percent cut that would drop the payment to $200.80. Meanwhile, the global rate would also see a 11.5 percent cut down to $384.29, while the proposed 1.8 percent reduction for the professional rate would lower the payment to $183.49.

The total scope of the proposed changes will see pathologists’ overall Medicare rates cut by 1 percent, while independent labs technical rates will jump by 4 percent overall. Finalized rates are expected to be announced in the fall, with rate changes taking effect Jan. 1, 2019. For more information on specific rate updates, please refer to the chart below.

MIPS 2019 Proposed Rule: What pathologists should watch for

While some groups have yet to fully turn their attention to fulfilling their 2018 Merit-based Incentive Payment System reporting requirements, CMS already has an eye on the 2019 reporting year and beyond. A number of changes for the program were recently proposed along with the 2019 Medicare Physician Fee Schedule Proposed Rule, although any proposals could still be revised before the agency releases the final rule late this fall.

For now, here’s a breakdown of the most significant proposals to keep on your radar:

Claims-based reporting finally being phased out

• CMS stated its intention to eventually eliminate the Medicare Part B claims-based reporting process in2017, so it’s no surprise to learn the agency is proposing to restrict the process to small groups of 15 orfewer physicians next year. That means those in large groups who have relied on claims reporting in thepast will need to seek out another method to submit their quality data, such as a qualified reportingregistry.

Category weighting remains stable for non-patient facing specialists

• Fortunately, the proposed rule has not changed the definition of non-patient facing specialists or altered the reporting exemptions offered tothese providers since the inaugural MIPS reporting year in 2017. Thatmeans most pathologists will again receive 85 percent of their overallMIPS score through their quality reporting, while the final 15 percent canbe earned by attesting to one high-weighted or two medium-weightedimprovement activities. Non-patient facing specialists will again beexempt from the new Promoting Interoperability (formerly AdvancingCare Information) and Cost categories.

Pathology claims-based quality measures set to be retired

• As part of the move away from claims-based reporting, CMS is also attempting to retire a number ofquality measures it considers to be topped-out (ie: have a very strong reporting rate, leaving little room forqualitative judgment between physician submissions). Of the eight existing measures in the pathologyspecialty measure set, the following three were proposed for elimination:

What does this mean for the average group? If you’re a small group who plans to continue reporting via claims, you’ll have three fewer available options to report on in the Quality category. While MIPS typically requires participants to report on six quality measures, specialists with a limited selection are only required to report on measures that apply to them. However, those reporting via the College of American Pathologists Pathology Quality Registry will have access to its expanded selection of quality measures that are available because of the registry’s status as a Qualified Clinical Data Registry.

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!

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CMS further clarifies 14-day rule changeCMS recently clarified that performing laboratories will soon be required to bill Medicare directly for the molecular tests and ADLTs exempted from the 14-day rule instead of relying on the hospital to bill Medicare on behalf of the laboratory. The agency will not begin enforcing this new billing requirement until January of 2019, meaning there's still time for reference and independent labs who traditionally have not billed directly for these services to prepare.

Medicare's long-term assault on prostate biopsies

If CMS approves the proposed 12 percent global payment cut for prostate biopsies (G0416), the code's global reimbursement will have suffered a 70 percent reduction throughout the past seven years! Has your lab mitigated the impact this shift has had on your revenue, or are you just weathering the storm?

Initial responses were due in June, so likely received a follow-up message if you failed to respond! Contact us if you still need assistance.