Case Studies

Avoiding scrutiny under the new CMS audit process

Posted by on Sep 5, 2017 in Case Studies, Latest News | Comments Off on Avoiding scrutiny under the new CMS audit process

With CMS recently announcing the agency is directing its Medicare Administrative Contractors to focus their audits and claim reviews on providers with consistently high error rates, it’s important to understand specifically what shortcomings could put your claims process under the microscope. CMS has said the goal of this new initiative, dubbed the Targeted Probe and Educate Pilot, is to prevent fraud, avoid unnecessary payments and to be less of a burden on providers whose billing operations are running smoothly. Select MACs will be asked to choose claims for services that carry a significant financial burden for Medicare, in addition to those that produce consistently high error rates. The good news is that unlike the old review system, which included all providers for a designated service during the initial round, providers who are already submitting claims with low error rates will be exempted from the review process. Unfortunately, while this new process will reward compliant health systems with less oversight, those who are found to be consistently falling short of CMS’s standard will need to show substantial improvement between reviews to avoid penalties. Those who are determined to still have an undesirable error rate after three rounds of review could face actions such as referral to a recovery auditor or 100 percent pre-pay review. Providers must display an ability to reduce their claims error rate between rounds of review in order to be removed from the cycle. So what does this mean for the average group? For starters, it’s more important to ensure your billing staff is informed of this change and is working with you to minimize coding errors. Even small mistakes could put you under the crosshairs of the new process. In one recent example, our audit team reviewed a caseload where  we found 2 percent of cases reviewed had a coding error that caused prostate TURP to be billed as G0416 to Medicare after the biller’s system mistakenly updated 88305 to G0416! Repeated mistakes like these are what MACs will be looking to identify. If you have any concerns about your claims process, now may be the time to consider preemptively bringing in a third-party auditor to review your work before the government comes calling. Vachette has worked with hundreds of clients throughout the nation and has the ability and expertise to identify and correct problem areas in your billing...

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Collection agency’s blunder leaves $565K in limbo

Posted by on Sep 7, 2016 in Case Studies, Latest News | Comments Off on Collection agency’s blunder leaves $565K in limbo

Collection agency’s blunder leaves $565K in limbo

A Midwestern pathology group we assist was recently being pushed by its third-party collection agency to pursue legal action for a number of unpaid accounts. Because of this discussion, we began receiving reports from the collection agency that were supposed to show the accounts the agency received each month from the group’s biller. However, as soon as we saw the account volume in the report, we knew something was off. A collection agency’s “error” led to them losing track of more than 3,400 worth roughly $565,000 during an eighth month period in 2016. The agency originally claimed they had not received these accounts until being confronted with proof that they indeed had. Since the pathology group’s biller was no longer responsible for the accounts once they were sent to collections, it’s clear there was very little oversight of the collection agency’s process. Although the report showed that only 114 accounts totaling about $15,000 had been sent over for collections from January to July of 2016, we knew that couldn’t be correct given that the agency had received 5,023 accounts from the group’s biller in 2015. When pressed, the collection agency said it hadn’t questioned the dramatic drop off in the volume of accounts they were receiving and instead blamed the biller by claiming they had loaded all accounts they were given. To debunk the collector’s claim, we worked with the group’s biller and their IT department to determine that during a three-month span from April to June of 2016, a total of 1,193 accounts were sent to the collection agency. Since the biller puts the accounts on a server that the collection agency must log into to download from, they were able to confirm through login records that the agency did in fact receive all the reports in question. When confronted with proof, the collection agency claimed the thousands of missing accounts were a result of an “error” on their end. They’ve since sent us and the pathology group a new report that shows they’ve received more than 3,500 accounts worth a total of $580,000 so far in 2016. Just a minor difference of more than 3,400 accounts and $565,000 from what they had originally reported. Needless to say, our group is now in the process of changing collection agencies. Who’s watching your revenue like this? Your biller won’t, since they write these accounts off (rightly so) as bad debt once they’re sent to collection. Even if your receiving reports from your collection agency, as our group was, it can be difficult to decipher them to determine if they’re working your accounts properly. That’s what we pride ourselves in at Stark Medical Auditing and Vachette Pathology: Finding the dollars that are slipping between the cracks! Give us a call today at 517-486-4262 if you’d like to talk with one of our team members about how our quarterly audits can help pad your...

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Is your outdated fee schedule leaving money on the table?

Posted by on Jun 17, 2016 in Case Studies, Latest News | Comments Off on Is your outdated fee schedule leaving money on the table?

Problem: We recently conducted a billing audit for a hospital-based physician group that purchases the technical component from its hospital when performing outreach work. However, a review of the group’s charges for TC work showed the rates they were contractually obligated to pay back to the hospital (which was the basis for their fee schedule) were significantly lower than what Medicare allowed almost across the board. When totaled, the difference between the charged and the Medicare allowed amounts for these codes accounted for a $57,000 loss of revenue in 2015, money that would have otherwise gone in the physicians’ pockets. Process: Since the group isn’t in an anti-markup state, we were able to quickly bump their TC fee schedule up to 100 percent of Medicare’s allowable rate. But, because their rates were so much lower than Medicare’s — 22 percent or less in multiple instances — it’s possible the hospital was nearly receiving less than cost for the use of its equipment. So why wasn’t the fee schedule updated sooner? In this instance, it essentially comes down to a matter of complacency. The group had had always reimbursed its full TC payments to the hospital, which in turn hadn’t updated its fee schedule for quite some time. While the hospital will now undoubtedly want to raise its reimbursement rate in future contracts, the group will be able to pocket the difference between the two rates in the meantime. This serves as a perfect example of why it’s important to regularly compare your fee schedule against Medicare’s to ensure it is up to date and helping you to maximize your revenue. Have questions or concerns about your fee schedule? Click here to request a free review...

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Check your billing after a system upgrade!

Posted by on May 26, 2016 in Case Studies, Latest News | Comments Off on Check your billing after a system upgrade!

Check your billing after a system upgrade!

By: Angela Granlund, Executive Client Administrator We recently had a pathology group whose hospital upgraded its Laboratory Information System (LIS).  Initially, everything appeared to be working smoothly after the upgrade. However, while reviewing date of service procedure volumes a couple months later, I noticed that two of the CPT codes that the group normally performs had no volumes being shown as billed out. The group had not changed their testing capabilities, so I contacted their billing agency to find out why these two codes were not being billed. The billing company said they had not noticed the drop in volume or questioned it. After researching the issue, the biller found that the codes were no longer coming through the feed from the hospital. Upon further investigation with the hospital, they learned that when the hospital updated to the new version of the LIS, a glitch caused these two codes from the feed to the billing company. If this error had not been caught, it would have cost the group about $13,000 in revenue. But once the omission was identified, the hospital fixed the issue, created a file of the missing codes reaching back to the date of the LIS update and sent it over to the billing company, who then filed the claims.  Fortunately, the issue was indentified soon enough that no denials for timely filing occurred. What do you need to do to make sure this doesn’t happen to you? Make sure you are in the loop when it comes to hospital or laboratory system updates or upgrades. Alert the billing staff or company when you know system changes are scheduled. Require your billing staff or company to track procedural volumes every month as well as review the data and question any variances. Do you get regular feedback from your biller? Are you confident that they haven’t missed billing anything for you?  If not, give us a call at 517-486-4262 – we can help you find...

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Biller’s fee schedule oversight a costly one for Southern pathology lab

Posted by on May 19, 2016 in Case Studies, Latest News | Comments Off on Biller’s fee schedule oversight a costly one for Southern pathology lab

Biller’s fee schedule oversight a costly one for Southern pathology lab

Problem: A quarterly audit for an independent Southern pathology lab unveiled the lab received $31.94 less for its global 88305 CPT codes (a microscopic tissue examination to provide diagnosis) than its contracted rate with a large commercial insurance carrier allowed on about 50 percent of the codes reviewed. When contacted about the discrepancy, both the lab’s third-party biller and the carrier said they were unaware of the problem and were unsure as to why it was occurring. Since this particular carrier accounts for roughly 38 percent of the lab’s payer mix, the auditor determined the client could have lost up to $82,000 in 2015 if 50 percent of the lab’s total 88305 volume was underpaid as the audit showed. Process: To confirm the error, our auditor went as far as to locate two different cases that were billed identically (even down to the pre-fix) except for the patient ID numbers. Both were paid different rates, solidifying that there was no discernible reason for the difference. We’re also working to determine how the biller initially followed up on this case since the audit shows they received payment from the insurance carrier for a batch of 88305s and their system automatically accepted the adjustment on the same day. On its face, it looks like the biller was simply accepting what the carrier was paying without question. We are now following up to see if there is any possibility to appeal to reclaim these underpayments. Recommendations: Follow up with your biller the moment you feel revenue isn’t adding up: In this instance, our client said he felt like he was losing $10,000 a month despite doing more work. His gut feeling was correct. Know the appeal limit in your contracts: Sadly, some contracts with carriers stipulate providers have only 180 days to appeal for an underpayment. After that, any money owed to the provider is lost. Performing a regular quarterly audit will help ensure underpayments are identified in time for an appeal to be made. Most importantly: Your billing staff or company MUST actually compare the paid EOB to the amount you are allowed to collect. This can be difficult since many billers have a “managed care tracking module” in their software that is often rendered useless due to constant fee schedule changes. This comparison takes time and money, but in the end, the client makes more money. Who’s watching your revenue like this? Is this happening to your practice and you simply are unaware? Questions about how we can help maximize your practice’s revenue stream? Contact Mick Raich, president of Vachette Pathology and Stark Medical Auditing, at mraich@vachettepathology.com or call us at...

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Case studies: Delayed Medicaid payments, unassigned codes and more

Posted by on Mar 28, 2016 in Case Studies, Latest News | Comments Off on Case studies: Delayed Medicaid payments, unassigned codes and more

Here are some of the latest case studies from the team at Stark Medical Auditing and Vachette Pathology. Case No. 1: Unassigned codes affect annual bonus Problem: A hospital-employed group has a clause in its contract that grants the group a bonus each year if the physicians meet a certain relative-value unit (RVU) threshold. However, the physicians were informed they narrowly missed the threshold in both 2014 and 2015 despite believing they had met their goal. Process: As part of a contract with the group, Stark tracks the RVU threshold on a monthly basis. While examining data in the reporting from their third-party biller back down to the CPT code level, we identified four codes that were not assigned an RVU in 2015 and therefore were not being counted toward the goal. The error was uncovered while the group’s client manager was reviewing a monthly report that showed zero work RVU’s calculated for the codes in question. The find on was then verified by using Medicare’s “Fee Lookup” tool to confirm there were work RVU’s assigned for those codes. After following up to ensure the missing codes were retroactively assigned with RVUs, we expect the group will meet its bonus threshold for 2015. The CPT detail for 2014 also is under review in case similar errors were made. Recommendation: Perform quarterly audits to ensure the integrity of data reporting from your biller. Consider a third-party auditor to verify results. If a group relies on reporting from its biller to submit data for bonuses similar to this, it has only the biller’s assurances that the data is correct. A third-party auditor can track this data regularly to discover reporting issues before they begin affecting your revenue.   Case No. 2:  Delayed start for state managed Medicaid causes payment gaps Problem: A behavioral health provider in Iowa was not receiving Medicaid payments because of the delayed start of the state’s managed care program. Process: The transition from traditional Medicaid to a managed Medicaid product is causing headaches for many behavioral health care providers, as the Iowa provider undergoing this transition can attest. Although CMS planned to launch Iowa’s managed care program in January after terminating the previous managed care organization’s (MCO) Medicaid contract in December, multiple start-date delays from CMS have led to a months-long payment gap. The Iowa provider is part of an association that’s working aggressively to develop contracts with the new MCOs. However, the delay in the start date for the new MCOs created issues because the state program itself (Iowa Medicaid Enterprise) did not create a contingency plan for this delayed start. Because of this lack of foresight, IME is now handling all of the behavioral health care claims processing on a rather outdated technology platform with limited staffing. On top that, IME has been providing different directions for claim filing to each provider, which has required the providers to restructure internal systems to get claims processed efficiently and out the door. “It’s been a huge issue and many providers are just now starting to see payments here in March,” said Jessica Jankowski, executive client administrator for Vachette and Stark. “However, several of their services still aren’t being paid for various reasons that IME has yet to explain.” Recommendation: Start preparing for change now if you know an MCO is coming in. Most of the population in states following this route will have to choose a managed Medicaid product. Learn how this transition could affect your payer mix, how the networks are structured and if you will need additional contracts, among other important details. Case No. 3:...

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