Microsoft PowerPoint - Jackson Presentation.ppt ...
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CONTINUUM OF CARECONTINUUM OF CARE
CONTINUUM OF CARECONTINUUM OF CARECONTINUUM OF CARECONTINUUM OF CARE
OFFICEOFFICE ASCASC
CONTINUUM OF CARECONTINUUM OF CARECONTINUUM OF CARECONTINUUM OF CARE
Radiology
OFFICEOFFICE ASCASC
Laboratory
H it lHospital
Letters
Pathology
CONTINUUM OF CARECONTINUUM OF CARECONTINUUM OF CARECONTINUUM OF CARE
OFFICEOFFICE ASCASC
PATHOLOGYPATHOLOGY
CONTINUUM OF CARECONTINUUM OF CAREbLab
OFFICEOFFICE OFFICE
PATHOLOGY
OFFICE
PATHOLOGY
PATHOLOGY LAB
PATHOLOGY LAB
PATHOLOGY LAB
PATHOLOGY LAB
CONTINUUM OF CARECONTINUUM OF CAREh l iPathologist
OFFICEOFFICEOFFICEOFFICE
PATHOLOGISTPATHOLOGIST
PATHOLOGISTPATHOLOGIST
LAB DATALAB DATALAB DATALAB DATA
106,000 CLIA registered Physician Office Labs (POLs)(Half only do CLIA waived labs)(Half only do CLIA waived labs)
5,200 CLIA registered Independent Labs
8,600 CLIA registered Hospital Labs
C L IA Reg is tered L abs Phys ician Labs :g Phys ician Labs :C L IA waivedtests only
P hys ician Labs
5,2008,600
Phys ician abs
Independent53,0053,000
Labs
Hospital Labs
Pathology precedentPathology precedentPathology precedentPathology precedent
Dermatologygy
Urology
Gastroenterology
Integration of care : reduced costsIntegration of care : reduced costs
PathPath
ASCASC
OfficeOffice
OFFICEOFFICE
PATIENTPATIENT ASCASCPrimary Care
Primary Care
LABLABLABLAB
disclaimerdisclaimer
This is a untrained gastroenterologist’s attempt to de-code Byzantine legal permutations within CMS. y g p
Retain a knowledgeable lawyer before proceeding.
State LawsState LawsP h l S iP h l S iPathology ServicesPathology Services
Direct Billing
ArizonaCalifornia
Anti-Markup
CaliforniaFlorida
Disclosure
ArizonaConnecticut
MassachusettsNevadaNew JerseyNew York
MichiganUtahOregonWashington
DelawareLouisianaMaineMarylandNew York
Rhode IslandLouisianaOhio
Washington MarylandNorth CarolinaOhioPennsylvania
South CarolinaTennesseeIowaMaryland
TexasVermontNew JerseyTennesseeMaryland
MontanaKansas
TennesseeUtah
Stark LawsStark LawsStark LawsStark Laws
Prevents referrals of designated health services by physicians to entities in which they have a physicians to entities in which they have a financial interest
Exception: “in-office ancillary services”
Stark LawStark LawStark LawStark Law
Designated Health Services (DHS)ExclusionExclusion
In-Office Ancillary Services (IOAS)
CMS 2008: Pod labs rulingOn-site vs. Off-site
StarkStarkStarkStark
Lab must be wholly owned by practice
Lab can serve needs of the practice’s patients only
Lab needs to be on premises
Pathologists must do the work in the lab where the specimen is prepared.
AMA Code of EthicsAMA Code of EthicsAMA Code of EthicsAMA Code of EthicsSection 8.09Section 8.09
Physicians focus is on quality and not economics
No mark-up for services by othersp y
Medicare and anti mark upMedicare and anti-mark-up
Pathologist must do “substantially all” (75%) professional services for that group.p g p
OR
Site-of-service option:TC must be performed and supervised and PC performed in the billing gastroenterologist’s officeperformed in the billing gastroenterologist s office
IOASIOASInIn--Office Ancillary ServicesOffice Ancillary Services
Performed in “Centralized Building”
Who bills for services? Who is the “service group”?1. Service group must be a group practice, “super group”
or consortium.
2 Person providing pathology specimens2. Person providing pathology specimensReferring physician (i.e. gastroenterologists)
Member of the group (i.e. pathologist who is employee or owner)
Individual supervised by a member of the group (generally does not apply)
IOASIOASInIn Office Ancillary ServicesOffice Ancillary ServicesInIn--Office Ancillary ServicesOffice Ancillary Services
(continued)(continued)
Follow Medicare Billing and Reassignment RulesReassignment: Physician may bill for services performed by an employed or contracted physician.
PathologistPathologistPathologistPathologist
Independent contractor
Employment agreementMust be “bona fide”
Fair market compensationFair market compensation
Written agreement (generally a year or more)
Compensation not reflective on referral
Malpractice & LiabilityMalpractice & LiabilityMalpractice & LiabilityMalpractice & Liability
Review current policy
There is increased exposureErrors & omissions by pathologist
Inadequate supervisionInadequate supervision
Negligent hiring
Billing errors: CMS fraud and abuseBilling errors: CMS fraud and abuse
Pod or Condo LabsPod or Condo LabsPod or Condo LabsPod or Condo Labs
Largely eliminated for Medicare patients by CMS in 2008.
Finalized in March 2009 after court challenge
Lab DevelopmentLab Development
PathologistPathologist
Physician Physician
Pathology Consultant•Construction•Equipment
Pathology Consultant•Construction•Equipment Physician
PracticePhysician Practice
Equipment•Personnel•Contracts•Certification•Insurance
Equipment•Personnel•Contracts•Certification•Insurance
PayorPayor
Insurance Insurance
Pathology LabPathology Lab
PC Professional Component
TC Technical Component
PC / TC BundledPC / TC Bundled
Traditional and historical model was for a hospital toown the lab (or partner with pathology group) and bill the TC.
Pathology group would then bill PC
ScenariosScenariosScenariosScenarios
PC TC PC/TC
1 32
IN-OFFICE
1 IN OFFICE PC1. IN OFFICE PC2. IN OFFICE TC3. IN OFFICE PC / TC
Scenario 1Scenario 1IN OFFICE PC
PC
IN-OFFICE
• Pathologist does bulk (75%) work with group.g ( ) g p
• No TC mark-up. TC bill submitted by out-sourced lab
• Un bundled bill (PC only) submitted• Un-bundled bill (PC only) submitted
Scenario 2Scenario 2IN OFFICE TC
TC
IN-OFFICEN O C
• Practice can bill TC (unbundled)
• Pathologist (not in-house): Pathologist bills for PC• Pathologist (not in-house): Pathologist bills for PC
• Practice can share ownership of on-site lab with other practices in building.
Scenario 3Scenario 3IN OFFICE PC / TC
PC / TC
IN-OFFICEN O C
• Practice can bill PC/TC bundled.
Scenario 3.1Scenario 3.1IN OFFICE PC / TC but multiple satellite
locationsoc o s
PC / TC
IN-OFFICE
• Practice can only bill Medicare TC at the main office and is subject to anti mark up at satellite officesand is subject to anti-mark-up at satellite offices
•Practice can bill PC if the pathologist reads at the p gsatellite office
System savingsSystem savingsSystem savingsSystem savings
Reduced administrative costElectronic interface with office EMRElectronic interface with office EMR
Charge pass to billing department / PM
Data transfer from pathology to ASC
No courier
No sales representative
Where’s the path???Where’s the path???
System savingsSystem savingsSystem savingsSystem savings
Move specimen processing out of hospital settingsg
Ultimate optimizationNarrow scope of operationNarrow scope of operation
Prompt turn around
On-site review
QualityQualityQualityQuality
Improved dialogue between endoscopist, nursing and pathologist: “vertical” integration of patient data
Pathologist has access to clinical information
Pathologist can tailor report to specific clinical questiong p p q
Expands team approach to patient care
Data mining and query functions (Pay For Performance) Data mining and query functions (Pay For Performance) as pathology results become integrated and linked to endoscopic findings, diagnosis, and clinical outcomes.
Expectations if you build your own labExpectations if you build your own labp y yp y y
Report program: expect high quality pathology report including photos and language that is p g p g gclinically applicable
Fast turn around
Easy access to second opinion
Transparency between the gastroenterologists and pathologists when a second opinion is sought
Expectations if you build your own labExpectations if you build your own labp y yp y y
Board certified pathologists
CLIA approved lab with adequate space
Pathologists must have easy access to relevant clinical information
100% accuracy matching specimen to patient (ideally no data re-entry).
SuggestionsSuggestions
Work with a knowledgeable consultantCan also helps keep legal fees minimizedCan also helps keep legal fees minimized
300 square feet + pathology reading office
Dialogue with your local pathology group
P l ’ iProcess only your group’s specimens
ObservationsObservationsObservationsObservations
Consolidated (TC / PC) billing is less confusing to the patientp
Pathology trendsPathology trends??
Movement of pathologists towards employees and subcontractors
Diminishing of hospital centered pathology with growth of ASCsg
Improved partnering between clinicians at point-of-care and pathologistsp g
Future trendsFuture trendsFuture trendsFuture trends
CMS may regulate PC from Independent Contractors
Pathology lobby advocating their interests
Molecular pathology:
Expanding partnerships betweenPathology and radiologyPathology and radiology
Further sub-specialization of pathology
In house liver biopsy
Non-endoscopic specimen collection
NPPs role expansion to endoscopy
Data sharing and integration
OfficeOffice
Data sharing and integration
O ceO ce
PMSPMSLabLab
ASCASCASCASC
PathologyProgram ASC
?
?
Patient EMR
?
Patient EMR record
Hospital data
Capsule endoscopy
Radiology
Pharmacy
O t id h i i
PracticeManagement
Outside physicians
Patient communications
OthSystem Other
Insurance
AP Lab Arrangements
PC TC PC/TC
ab a ge e ts
PC TC PC/TC
E Mi Mi MiExpenses Microscope
Software
Microscope
Software
Microscope
Software
Camera Camera
Technician
Camera
TechnicianTechnician
Consultant
Technician
Consultant
Space Space
EconomicsEconomicsEconomicsEconomics
Average 1.8 specimens per endoscopy
Medicare reimbursement: $90 - 100 / specimen (global fee)$ p (g )
TC : 60% / PC : 40%
P h l C lPathology Consultants
GI Pathology Partners
Lakewood Pathology
Path Lab Solutions
Path Options
Physicians Right PathPhysicians Right Path
Twin Crest Group
Data accessionData accession
specimens specimens
tissue grossingtissue grossing
Tissue prepTissue prep
Tissue embeddingTissue embedding
Wax embed prepWax embed prep
Wax coolingWax cooling
Thin sectioningThin sectioning
StainingStaining
Slide prepSlide prep
Final readFinal read
OFFICEOFFICEGI
PATIENTPATIENT ASCASCPrimary Care
Primary Care
LABLABLABLAB
questions
??