Mick Raich, Vachette Pathology
Earlier this year I wrote a brief article on the changes with 88342 and the new G codes G0461 and G0462. This article proved very insightful to me and many others. It helped me understand how I was looking at things incorrectly, and it helped our client practices understand their revenue shortfalls.
It has been six months since that piece; let’s take a quick look back at the revenue losses we predicted, compared to actual loss. Remember this is only for Medicare payments.
We reviewed a lab which bills globally and predicated a loss of $159,000. Originally we figured their losses as of May 2014 would be about $16,611. In actuality, their loss is $16,248. See the graph below.
For a group which bills professionally, we only predicted a loss of about $14,000 by May 2014. In actuality the loss is $19,000. See the graph below.
As you see with these two examples, most of our loss predictions were less than actual losses. When tracking these things you have to be careful to look at date of service data and to look for claims that have already been fully adjudicated.
We find that many of our groups and their billers are still suffering from a bad process to handle these cases.
We have about 70 groups, labs and hospitals under contract, and we provided these projections to them last year. Currently we are tracking losses for all our clients. We are also aggressively auditing our clients each quarter to find missing and denied cases that have not been appealed. There are millions of dollars left on the table in this area.
Here is exactly what you should do to track these cases and prevent these losses.
Sample IHC Auditing Process
1. Request cases from physician.
a. Request an appropriate number of pathology reports that have IHC CPT codes assigned. (Please note our groups are auditing ALL of their IHC cases.)
i. Dates of service should be at least six months prior to the audit start date.
ii. Reports should be randomly selected (the biller should NOT be involved in the selection process).
2. Receive initial cases from physician.
3. Send initial cases to biller requesting the following documentation:
a. HCFA form;
b. explanation of benefits from primary and secondary insurance with adjustment codes;
c. and patient transaction or history screen that shows payment and adjustment posting and current balance.
4. Receive initial case information from biller.
5. Match case information.
a. Attach the biller’s documentation to the pathology report received from the physician’s office.
b. Compare reported IHC CPT codes to billed CPT codes to confirm the correct CPT codes have been billed according to IHC guidelines.
c. Confirm correct number of units have been billed to carrier according to IHC guidelines.
d. Confirm correct IHC CPT codes were billed to Medicare or the insurance carrier according to insurance carrier guideline. (This is the hard part and where you must build a matrix to review each carrier.)
e. Confirm date of service to verify correct IHC CPT codes were billed to carrier per IHC guidelines.
f. Confirm insurance is allowing all units billed for IHC CPT codes.
g. Compile questions that require further explanation from biller.
6. Send initial questions to biller.
7. Receive question documents back from biller.
a. Review answers from biller and document case audit finding.
8. Complete case audit.
a. Categorize case audit findings and report in audit summary.
9. Perform payer analysis by EOB.
a. Confirm IHC CPT allowed amounts by insurance are being paid according to the managed care contract reimbursement language.
10. Track every case to payment or bad debt and zero balance
The best option is to audit your billing, then work forward.
I will release a final version of this comparison in February of 2015 to review actual dollars lost compared to our total predictions.
Although these types of predictions are not always 100% correct, it is important to at least considering your losses and be proactive. For example, next you should be looking at the proposed CMS fee schedule for 2015 and building projections for those cuts.
If you have any questions please contact me, Mick Raich, at 866-407-0763 or 517-486-4262 or firstname.lastname@example.org.