News, Analysis, Trends, Management Innovations for
Clinical Laboratories and Pathology Groups

Hosted by Robert Michel

News, Analysis, Trends, Management Innovations for
Clinical Laboratories and Pathology Groups

Hosted by Robert Michel
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Exact Sciences Sues Humana Over Cologuard Coverage in Spat over How Insurer Reimburses for This Clinical Laboratory Test

Filing a complaint with the Louisville division of the District Court for the Western District of Kentucky, Exact Sciences seeks payment from Humana for at least 4,664 Cologuard tests as well as coverage for the procedure in the commercial plans offered in mandate states

Citing more than $800,000 in unpaid service fees and damages, the Exact v Humana lawsuit is the latest example of the on-going struggle between health insurers and clinical laboratories offering proprietary and patent-protected lab procedures.

Exact Sciences Corp. (NASDAQ: EXAS), and Exact Sciences Laboratories, LLC (Exact) allege that Humana (NYSE: HUM) has denied 120 claims in Kentucky worth approximately $70,000 as well as 293 additional claims in other states with coverage mandates worth approximately $169,000.

Exact claims that attempts to appeal denied claims resulted in payment for some services but that more than half remain rejected. They also report roughly 350 claims in which Humana underpaid.

They are seeking full payment for all claims made since the start of 2014 in Kentucky, Georgia, Missouri, North Carolina, Texas, Illinois, Nevada, and Oklahoma. (more…)

CMS Begins the New Year by Instituting Fines for Insurance Payers That Issue Error-Filled Provider Directories

Increased accuracy in listings should benefit in-network medical laboratories and anatomic pathology groups

Regional and smaller medical laboratories will welcome a new enforcement initiative by the Centers for Medicare & Medicaid Services (CMS). Health insurers now will face fines as high as $25,000 per beneficiary as a sanction from regulators in many states for errors in provider directories that can result in patients receiving surprise out-of-network bills.

As the number of consumers with high-deductible health plans has grown, the demand for more price transparency by physicians, hospitals, and other healthcare providers has increased, with states such as New Hampshire and Colorado legislating public price transparency websites.

Now the federal government is taking another step toward increased transparency in healthcare by fining payers whose provider directories are not current and include inaccurate listings that may cause consumers to unknowingly select out-of-network providers. This is especially important as insurance providers continue to narrow their provider networks. Increased accuracy in provider directories should help clinical laboratories and pathology groups that participate in insurance networks. (more…)

Even as Medicare ACOs Delivered Mixed Results in 2014, Primary Care Physicians Were Awarded Biggest Share of Bonus Payments

AJMC study shows ACOs that allocate majority of shared savings to primary care providers are more likely to generate savings

When it came time to pay bonuses to Medicare’s Pioneer ACOs and Shared Savings Program (MSSP) ACOs based on 2014 results, a substantial proportion of the payments went to primary care physicians compared to hospitals and specialist physicians. Significantly, only a minority of these ACOs qualified for bonus payments.

Pathologists and clinical laboratory managers watching the growth of ACOs will find it notable that primary care doctors received 46% of the shared-savings bonuses in the program’s first two years. Hospitals received 27% of the incentives while 20% went to specialists, according to a Modern Healthcare report.

High Expectations That ACOs Can Help Control Healthcare Costs

Twenty Pioneer ACOs and 333 Medicare’s Shared Savings Program (MSSP) ACOs combined to produce more than $411 million in total savings in 2014, although only 29% of the organizations generated enough savings to earn a bonus, a CMS Fact Sheet indicated.

“These results show that accountable care organizations as a group are on the path towards transforming how care is provided,” stated CMS Acting Administrator Andy Slavitt in a statement. “Many of these ACOs are demonstrating that they can deliver a higher level of coordinated care that leads to healthier people and smarter spending.” (more…)

As ICD-10 Implementation Approaches October 1 Deadline, Clinical Pathology Laboratories Wonder if Providers and Payers Will Make a Smooth Transition

Medical laboratories and anatomic pathology groups could face payment delays if physicians fail to code lab test claims properly using ICD-10 codes

Just weeks remain before the implementation to ICD-10 begins. This will be a delicate time for clinical laboratories and anatomic pathology groups, since labs must rely on physicians to provide accurate ICD codes that labs must submit on test claims in order to be reimbursed by payers.

The much-delayed shift from ICD-9 to ICD-10 diagnosis codes will take place on Thursday, Oct. 1. When clocks strike midnight, years of debate over whether the conversion will create a financial hardship on physicians—and in turn disrupt payments to clinical laboratories and anatomic pathology groups—will begin to be answered.

The Medicare program requires appropriate ICD codes on medical laboratory test claims for Medicare patients. That is one reason why clinical laboratories and anatomic pathology are financially vested in a smooth conversion process. All Medicare Part B claims for medical laboratory tests must be submitted with an appropriate International Classification of Diseases (ICD) code provided by the physician who ordered the lab tests. The Medicare program will not reimburse lab test claims without an appropriate ICD code. (more…)

Many Pathologists Participate in Medicare’s Quality Reporting and e-Prescribing Programs, but 40% of Providers Opt for Penalties over Compliance

Among all medical specialties, pathologists have a high rate of participation in both Medicare reporting programs

Many pathologists are aware of Medicare’s Physician Quality Reporting System (PQRS) and Electronic-Prescribing Incentive (e-prescribing) Program. But what is less known is that up to 40% of eligible doctors nationwide are opting to not participate and thus get paid less money from the Medicare program.

That high rate of non-participation is not true for one group of practitioners, however. Pathologists had the highest participation rate (78.7%) among specialties in PQRS and recorded the fourth-highest participation rate (80.3%) in the e-prescribing program! Pathologists received an average incentive of $246 for the 2013 e-prescribing program and $384 for the 2013 PQRS program. (more…)

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