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Who's Watching Your Wallet?

Vachette Monthly, May 2019

Dr. James Richard on seeking the office of CAP President-Elect Roughly two years ago, Dr. James Richard made a commitment and decision. He was completing the final year of a four-year term as Speaker of the House of Delegates of the College of American Pathologists (CAP). The Speaker is responsible for listening to the needs of all CAP members and articulating those needs to the CAP Board of Governors, where they create services and products to address those needs. The decision was to run for CAP President-Elect. The commitment was to make sure the services and products the CAP turned out would directly respond to member needs.

“I said to myself, ‘You know what? I’ve been exploring member needs for six years,’” Richard, D.O., FCAP, commented. “I can use that base to make a difference by being on the policy, services and product-making side of things.”

Colleagues said, “'Jim your kids are out of the house, you’ve got grandkids, is this what you want to be doing with your time?' I thought a lot about that before deciding. I had to take some of the advice that I always told my kids: ‘Fill your time with meaningful things. Only you can determine what is meaningful.’ Becoming the CAP President would give me the opportunity to make a difference in the profession I love and for the colleagues who comprise it.”

What Richard said he didn’t expect is that he’d eventually end up in a contested three-way race alongside Dr. Timothy Allen, M.D., J.D., and Dr. Emily Volk, M.D., FCAP, both of whom currently serve as CAP Governors. The three will face off in the upcoming CAP election that runs from July 23 to August 22.

-- Richard, 5

Recent audit findings

• We sound like a broken record, butwe still consistently need to remindbillers not to improperly alter claimsto circumvent MUE edits. Justrecently, we reviewed a case wherethe documentation did not support88342x3/88341x8, however, the billersent the claim in that way due toMUE edits. This is a significantcompliance issue.

• Despite the CCI edit, 88342/88341billed with 88360 can be approvedand covered when properly appealed.We recently reviewed a case whereinsurance denied this as non-covereddue to bundling. No appeal wasperformed and full balance of $180.00was adjusted off because the billerdidn't know it was payable!

• We recently encountered a lab thatwas choosing to bill for both panelsand their individual CPT codes. Just atad bit duplicitous, no?

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At Vachette, we specialize in consulting and auditing for labs and pathology practicesWe have been working with hospitals, laboratories, and hospital-based groups for more than 16 years. Visit vachettepathology.com, call 517-486-4262, or contact Dustin Suntheimer, vice president of sales and marketing, at 734-972-2693. Our experience and expertise are second to none!

View MIPS feedback While scores won't be finalized

until later this year, groups should log in to qpp.cms.gov to view preliminary 2018 feedback.Facing a

merger?Is your health system

merging groups? Who can you turn to for

advice on these changes? Vachette specializes in

this type of work.

Michigan BCCCNP rates receive another bumpHeads up for Michigan providers participating in the Breast and Cervical Cancer Control Navigation Program: As of April 1, BCCCNP rates have received another bump. This is welcome news as it represents the third fee schedule increase providers have seen in this fiscal year.

The full updated fee schedule can be downloaded here.

Payers turning off certain codes?

Have you had payers turn off payment for certain CPT codes, even when these codes are listed in your contract? We’ve seen this lately even with carved out CPT codes.

How have you been handling this? Have you simply been accepting this as the new status quo?

NILA gathering public feedback on PAMA cuts

Laboratories and pathology groups who have been feeling the crunch created by reimbursement cuts under the Protecting Access to Medicare Act (PAMA) were recently asked to sound off in a public survey being conducted by the National Independent Laboratory Association.

The vast majority of tests impacted fall under a three-year reporting cycle, meaning applicable labs are required to report their payer data from January to June of 2019 during the first quarter of 2020. New reporting requirements will also likely trigger hospital-outreach laboratories to submit their private payer data during this cycle.

As NILA and other industry organizations continue to work with legislators to make PAMA's overall effect on the lab industry clear, don't hesitate to reach out to us if you're struggling to understand how to best collect and report your private payer data in order to avoid penalties for noncompliance!

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Do you qualify for automatic facility-based

MIPS scoring?

Still weighing your Merit-based Incentive Payment System reporting options for 2019? If you're a hospital-based group, you may be eligible for the new facility-based scoring mechanism that was introduced this year. If you performed at least 75% of your covered professional services in a hospital setting, then you're likely eligible to receive automatic scores in the Quality and Cost categories based on the hospital's performance in the Value-based Purchasing Program. While scores under this option may be difficult to predict, it's worth considering this route given that it is a free reporting option. Let us know if you need help determining whether this could apply to your group!

Pathology Consultative Services

For over 25 years, providers have relied on Cleveland Clinic Laboratories for personalized and comprehensive pathology services.

Our expert staff provides primary diagnoses, subspecialty

consultations, and second opinion consults that form the

basis for effective patient care.

For more information, please visit clevelandcliniclabs.com.

Anthem aims to cut lab payments in several statesAfter significantly slashing payment rates for lab services in Missouri late last year, it appears Anthem is now moving to institute similar cuts in a number of other states, including Ohio, California and Indiana, according to letters recently received by Vachette clients.

Many of these new rates reflect a more than 70 percent drop from previously negotiated reimbursements for many groups and are a significant reduction from 2019 CMS rates published in the Physician Fee Schedule and Clinical Laboratory Fee Schedule.

New rates will go into effect in Ohio for covered services provided on or after July 10. Providers in KY, NY, CO, CT, GA, NH, ME, MO, NV, VA and WI are also expected to experience similar cuts in the near future.

According to the letter sent to Ohio providers:

“For Blue Traditional, Blue Access, Blue Preferred, Blue Priority, OH Exchange PPO, OH Exchange HMO, OH Pathway Group HMO and Anthem Medicare Advantage Covered Services, the fees for:

• Rates for codes in the 80000-89999 series will be modified to reflect the rates currently in place fordedicated laboratory services providers. Certain in-office testing will be exempt from the changes.

• Rates for 0362T and 0373T will be reduced to be consistent with the recent changes to the codesdefinitions reducing the time per unit from 30 minutes to 15 minutes.-- ANTHEM, 4

Pathology & Laboratory

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ANTHEM --

Those who disagree with these changes must send a Notice of Objection within 10 days of receipt of the letter.

As we have recently experienced with Anthem’s policies on ER visits and MRIs, Anthem is making moves to drastically cut reimbursements to ancillary providers at a time when its overall membership continues to grow, including the addition of 1.2 million new members and a reported 9.2 percent revenue growth to $24.4 billion in Q1 of 2019. It appears they’ve now turned their attention to making similar changes for pathology services.

As we've done in Missouri, we will continue to leverage our resources to push back on these misguided rate cuts. Recently, we were informed Anthem was “reconsidering” the changes after receiving significant pushback from St. Louis-area labs.

Additionally, the Ohio Society of Pathologists Board of Governors and the California Society of Pathologists have already sent an urgent email to members urging them to be on the lookout for these notices.

In the meantime, please reach out to us at to see the full list of codes affected by these cuts, or to discuss options if your group is notified of any similar reductions in the near future.

New molecular LCDs to go into effectSeveral Medicare Administrative Contractors (MACs) will soon have new Local Coverage Determinations (LCDs)

in place for various FISH testing codes that will require providers to list a diagnostic code supporting medical necessity in order to receive payment.

The following CPT codes are impacted: 88271, 88273, 88274, 88275 and 88291.

Required diagnostic codes: C94.6, D46.0, D46.1, D46.20, D46.21, D46.22, D46.A, D46.B, D46.C, D46.4, D46.Z, D46.9

Effective dates:Palmetto -- 4/8/2019

CGS -- 5/6/2019WPS -- 5/13/2019

Noridian -- 6/3/2019

RICHARD -- The winner will serve a five-year term that consists of two years as President-Elect, followed by an additional two years in the role of President and one final year as the Immediate-Past President.

When asked what distinguishes him as a candidate in this crowded field, Richard pointed to his six years spent serving as Speaker and Vice Speaker of the CAP House of Delegates from 2012-2018, a position in which he not only needed to articulate member needs, but also routinely negotiate and build consensus.

Richard also mentioned his success in business negotiations throughout his career, including securing the 2014 sale of CAP-Lab, LLC, where he was a partner and lab director, to Sparrow Hospital, where he serves as the Medical Director of the Laboratory and Department Chairman. Richard says he is particularly proud of the fact that the deal included raises for all of the hospital pathologists and permanent positions at the hospital for every employee.

“I’m the ideal candidate because I have a well thought out plan of action and a history of being able to deliver,” Richard said.

After his years serving the House of Delegates, Richard believes there are two primary concerns facing pathologists. The first is protecting the livelihood of the profession, which he characterizes as “being able to make a good living while being able to make the decisions required to deliver good patient care.”

The second concern Richard said he most commonly hears is a desire to elevate the status of pathology within the broader medical community.

“To elevate your stature in the medical community, that means that more than just the people in your own department have to say you’re good,” Richard explained, adding that pathologists sometimes have a tendency to talk too much with other pathologists. “Elevating our stature means people other than pathologists acknowledging the value that we bring to the table.”

Part of his plan to address this is to build strategic alliances to strengthen CAP’s voice. Richard said becoming more in-step with state pathology societies is a start.

“Grassroots-level participation is a must,” Richard said. “Also, communication goes a long way. An educated grassroots team will articulate what your collective needs are.”

Richard may be contacted directly via his campaign website.

Dr James Richard, left, talks with Vachette Vice President of Sales and Marketing Dustin Suntheimer last month.

Richard is seeking the office of President-Elect for the College of American Pathologists. An election will be held for CAP members from July 23 to August 22.