COVID-19: Insurers Exempt from Covering Workplace Testing

Must Cover “Medically Appropriate” Tests Only

The rapid rollout in March of the federal FFCRA (Families First Coronavirus Response Act) and CARES (Coronavirus Aid, Relief and Economic Security Act) Acts – and specifically section 6001 of the FFCRA, which defines requirements for insurers – has left providers, labs and insurers uncertain, at times, of their respective responsibilities for COVID-19 testing.

Laboratory News Brief – May 2020

Keeping you in the know on the constantly changing world of medical billing and reimbursement, Quadax compiles industry news and articles covering important revenue cycle topics impacting the lab industry. 

Icon-Virus Coronavirus (COVID-19)
 COVID-19 Testing, Treatment and Future Outlook (WEBINAR)
360DX
This 6/4 webinar will discuss the current status of COVID-19 testing, treatment and other aspects of the current pandemic as they relate to getting this outbreak under control.  [Read more]

CDC streamlines lab test result reporting by sharing COVID-19 results reported to public health agencies with HHS system
AHA
To streamline the reporting of COVID-19 lab test results, the Centers for Disease Control and Prevention yesterday encouraged all U.S. hospital laboratories to submit their COVID-19 testing information to their state or local public health department following their normal protocol for reportable conditions. [Read more]
 Lack of routine testing puts labs in financial pinch
Becker’s Hospital Review
Two of the largest diagnostics companies, Quest Diagnostics and LabCorp, have both taken a hard hit to their finances due to a lack of routine testing.  [Read more]
 COVID-19 Information
CAP
COVID-19 Resource Center for labs including recent updates and responses to COVID-19 questions. [Read more]
 COVID-19 Precipitates Sharp Decline in Cancer Testing, Diagnoses
Clinical OMICs 
Regular screening is down due to reduction in the number of people having medical appointments, and repurposing of lab resources toward providing COVID-19 testing has impacted these labs’ ability to providing oncology testing. [Read more] NIH Launches $1.5B Rapid COVID-19 Testing Technology Challenge
Clinical OMICs
A new initiative announced by the National Institutes of Health, backed by a $1.5 billion investment from federal stimulus funding, aims to speed innovation, development, and commercialization of COVID-19 testing technologies.  [Read more]
 Quality Issues Your Clinical Laboratory Should Know Before You Buy or Select COVID-19 Serology Tests (WEBINAR)
Dark Daily
Dark Daily is offering this FREE webinar on 5/21 in support of clinical laboratory professionals and pathologists. [Read more]
 With So Many New COVID-19 Serology Tests Obtaining EUAs from the FDA, How Can Clinical Laboratories Identify Tests That Should Perform Reliably? (ADDED 5/20)
Dark Daily
As federal and state officials ease many regulatory requirements to speed new COVID-19 serology tests to market with minimum data about performance, labs are left with important questions to answer on their own. [Read more] 
 Policy for Coronavirus Disease – 2019 Tests During the Public Health Emergency (Revised)
FDA
Immediately in Effect Guidance for Clinical Laboratories: FDA is issuing this guidance to provide a policy to help accelerate the availability of novel coronavirus (COVID-19) tests developed by laboratories and commercial manufacturers for the duration of the public health emergency. [Read more] Labs push back on WH testing claims citing lack of critical supplies
The Hill
Academic medical labs pushed back Tuesday on the Trump administration’s assertion that they are underutilizing COVID-19 testing equipment that could help increase the country’s diagnostic testing capacity. [Read more]

Icon-DNAMolecular DiagnosticsNew Method for RNA-Seq Helps Unravel Data from a Mixture of People
Clinical OMICs
The Souporcell technique could help study how genetic variants in different people affect which genes are expressed during infection or response to drugs. [Read more]
  
Financial Obligations Payer News
 Health Insurance Providers Respond to Coronavirus (COVID-19)
AHIP
List of health insurance providers activating emergency plans to ensure that Americans have access to the prevention, testing, and treatment needed. [Read more] COVID-19: Modified Ordering Requirements for Laboratory Billing
CMS MLN Connects (5/7/2020 Issue)
During the COVID-19 Public Health Emergency, CMS is relaxing billing requirements for laboratory tests required for a COVID-19 diagnosis. [Read more] Cost Share Covered for COVID-19 Antibody Testing
UnitedHealthcare 
UnitedHealthcare will cover FDA-authorized COVID-19 antibody tests ordered by a physician or appropriately licensed health care professional without cost sharing (copayment, co-insurance or deductible). [Read more]

Laboratory News Brief – April 2020

Keeping you in the know on the constantly changing world of medical billing and reimbursement, Quadax compiles industry news and articles covering important revenue cycle topics impacting the lab industry. 

Icon-Virus Coronavirus (COVID-19)
 Breaking News on Novel Coronavirus Testing
360DX
Breaking news on coronavirus testing, with real-time reporting on assays to detect the SARS-CoV2 coronavirus, which causes COVID-19. [Read more]

AACC Asks Congress to Wait on LDT Regulation During Coronavirus Outbreak
AACC
AACC called on lawmakers to pause consideration of a bill that would expand FDA regulation of laboratory-developed tests until the full effects of the virus on the healthcare system can be evaluated. [Read more] 
 Biodesix Begins Coronavirus COVID-19 Testing
Biodesix
Biodesix, Inc., a leading diagnostic company in lung disease, announced that it began SARS-CoV-2 Droplet Digital PCR (ddPCR) testing for the virus that causes COVID-19 and will immediately submit for Emergency Use Authorization from the Food and Drug Administration.  [Read more]
 COVID-19 Information
CAP
COVID-19 Resource Center for labs including recent updates and responses to COVID-19 questions. [Read more]
 COVID-19: A Catalyst For Innovation In Clinical Research?
Clinical Research News
The novel coronavirus (COVID-19) has presented numerous challenges for clinical research. While some trials for a COVID-19 vaccine have already begun, it will take time before any progress is made for a publicly available drug. And in the meantime, clinical trials not dedicated to the pandemic are struggling to remain operational. [Read more]
 What Hospital and Health System Labs Need to Know About Operational Support and Logistics During the COVID-19 Outbreak
Dark Daily
Dark Daily is offering this FREE 60-minute webinar in support of clinical laboratory professionals and pathologists. [Read more]
 Diagnostic Test Kits, Commercial Labs Granted Emergency Use Authorization In Wake Of COVID-19
Diagnostics World
The diagnostics community has come out in force to address testing issues for the novel coronavirus. As of April 3, 25 test kit manufacturers and commercial laboratories have been issued Emergency Use Authorization from FDA, and many commercial and healthcare system/academic laboratories have notified the FDA that they have validated their own COVID-19 test and have started patient testing. [Read more] Virtual Town Hall Series – Immediately in Effect Guidance on Coronavirus (COVID-19) Diagnostic Tests
FDA
On April 15, 2020, from 12:15 pm – 1:15 pm Eastern Time, the U.S. Food and Drug Administration (FDA) will host a virtual Town Hall for clinical laboratories and commercial manufacturers that are developing or have developed diagnostic tests for SARS-CoV-2. [Read more] FAQs On FDA Guidance For Clinical Trials During The COVID-19 Pandemic
IMARC Research
The FDA added an appendix with frequently asked questions and answers on its previously released guidance document on Conduct of Clinical Trials of Medical Products during COVID-19 Pandemic. Here are some key takeaways from the most common questions. [Read more]
 JAMA Coronavirus Disease 2019 (COVID-19)
JAMA Network
Browse the JAMA Network COVID-19 collection, including Q&A’s with NIAID’s Anthony Fauci, an interactive map of the outbreak courtesy of The Johns Hopkins Center for Systems Science and Engineering, and past publications on vaccine development, infection control, and public health preparedness. [Read more]
 FDA announces availability of reference sequence data for SARS-CoV-2
Medical Laboratory Observer
The Food and Drug Administration—in collaboration with the CDC, BEI Resources, NCBI and NIH— have developed quality-controlled reference sequence data for the SARS-CoV-2 reference strain for the United States. [Read more] 
Icon-DNAGenomicsCancers’ Complexities, Commonalities Detailed in Extensive Genomic Analysis
AACC
A massive undertaking involving more than 1,300 scientists from 37 countries reported in 23 papers shows the results of analyzing 47 million genetic changes in 2,600 genomes of 38 different tumor types. The Pan-Cancer Analysis of Whole Genomes presented what the researchers called “the most comprehensive study of whole cancer genomes to date.” [Read more]
  
Financial Obligations Payer 
 Blue Shield of California is offering providers up to $200 million during COVID-19 crisis
Healthcare Fiance 
The nonprofit insurer is working with two financial-services partners to provide financing guarantees, advance payments and restructuring of contracts. [Read more] UnitedHealth Group Accelerates Nearly $2 Billion in Payments and Support to Health Care Providers to Help with COVID-19 Financial Challenges
United Healthcare
UnitedHealth Group will accelerate nearly $2 billion in payments and financial support to U.S. hospitals and healthcare providers to help address the significant financial pressure many are facing due to COVID-19. [Read more]
  
Icon-Microscope Industry News
 Because of the COVID-19 Outbreak, AACC Reschedules Its Annual Conference to December in Chicago and Executive War College Reschedules Its Conference in New Orleans to July
Dark Daily
Two major clinical laboratory conferences reschedule: American Association of Clinical Chemistry moves from July to December 13-17 in Chicago and Executive War College moves from April to July 14-15 in New Orleans.
[Read more]

Laboratory News Brief – March 2020

Keeping you in the know on the constantly changing world of medical billing and reimbursement, Quadax compiles industry news and articles covering important revenue cycle topics impacting the lab industry.

STAT

The push to increase testing in the U.S. for the novel coronavirus that causes Covid-19 has hit a new stumbling block: shortages of key chemicals needed to start up and run the tests. [Read more]

Payer 

Availity is now Aetna’s provider portal
Availity
On April 30, 2020, Aetna is retiring NaviNet as their provider portal. Availity is now Aetna’s provider portal for all your eligibility and benefits, claims,
ERA /EOB, authorization and referral needs, and more. On Availity, you only need ONE user ID and password to work with Aetna and other participating payers in your region; and there is no cost to register. FREE webinars hosted by Availity and Aetna trainers are available to show tips and tricks for working with Aetna on Availity. [Register here] 

Reimbursement 

New Fast PATH Initiative Aims to Improve Prior Authorization for Patients and Doctors
AHIP
America’s Health Insurance Plans (AHIP), along with several of our member insurance providers, is launching the Fast Prior Authorization Technology Highway (Fast PATH) initiative to improve the prior authorization process. Electronic prior authorization is becoming more available to physicians but most still use manual processes to request prior authorizations, despite the common availability of online submission portals. Fast PATH aims to employ technology in the physician’s office to improve connections between insurance providers, doctors’ offices, and other care settings. [Read more] 
Declining Reimbursement in the Clinical Laboratory
COLA
The financial impact on clinical laboratories of the second year of PAMA-related cuts in Medicare’s Clinical Laboratory Fee Schedule (CLFS) is being felt into 2020. In addition to the Medicare fee schedule changes, Medicaid programs at the state level, and national and regional health insurers have moved swiftly to reduce reimbursement rates for clinical laboratory services. [Read more] 

Genomics

New Genomic Tests Aim to Diagnose Deadly Infections Faster
New York Times
Across the country, researchers and engineers are racing to perfect rapid genomic tests that could revolutionize how doctors diagnose and treat infections, but their cost may limit widespread use. [Read more] 
Blue Shield of California Covers Rapid Whole Genome Sequencing for Children With Rare Diseases
Healthcare Innovation
Blue Shield of California has become the first health plan in the United States to cover rapid and ultra-rapid Whole Genome Sequencing to help critically ill babies and children in intensive care with unexplained medical conditions receive precision care. [Read more] 

Coronavirus

How to use ICD-10-CM, new lab testing codes for COVID-19
AAP News
The introduction of 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) in the United States has produced an influx of patients into the health care system. While knowing how to diagnose and treat these patients is vital, being able to appropriately capture this information for data tracking and payment also is important. [Read more] 
Health Insurance Providers Respond to Coronavirus (COVID-19)
AHIP
Health insurance providers are committed to helping prevent the spread of the coronavirus strain COVID-19 by activating emergency plans to ensure that Americans have access to the prevention, testing, and treatment needed to handle the current situation. [Read more] 
CMS Sets Payment Rate for SARS-CoV-2 Testing
CMS
The Centers for Medicare & Medicaid Services announced it has set the payment rate for laboratories performing SARS-CoV-2 assays. Labs can begin billing for the tests in April for services occurring after Feb. 4, 2020. [Read more] 
Top insurers commit to easing cost barriers to coronavirus testing
Fierce Healthcare
AHIP — which includes the heads of top insurers like Humana, Anthem, CVS and Cigna — is working to mitigate the cost concerns around testing for coronavirus. In a recently released statement, AHIP stated they are committed to providing coverage for tests ordered by a physician. They also said they are working to ease network, referral and prior authorization requirements that could hinder access and their organizations would also potentially waive out-of-pocket costs for the tests. [Read more] 
CPT code expected soon to report and bill for coronavirus tests
Fierce Healthcare
The American Medical Association (AMA) is moving forward to approve a new CPT code for reporting novel coronavirus tests. The AMA said it hoped to fast track establishment of a new code to empower surveillance and laboratory testing in response to the spread of the coronavirus. [Read more] 
CMS develops specific billing code for coronavirus test
Healthcare Finance
The Centers for Medicare and Medicaid Services has developed a new Healthcare Common Procedure Coding System code for providers to bill the lab test of the coronavirus. The HCPCS code enables labs to bill for the specific test instead of using an unspecified code. The Medicare claims processing system will be able to accept this code on April 1 for dates of service on or after February 4. [Read more] 
Insurers will cover testing of coronavirus, AHIP says
Healthcare Finance
Insurers are voluntarily covering the diagnostic testing of the coronavirus, when ordered by a physician. Cigna and Aetna are waiving consumer co-pays, cost sharing and other out-of-pocket costs. [Read more] 
CDC Releases Interim Coding Guidance for Coronavirus
Journal of AHIMA
The Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS) will implement a new diagnosis code for reporting the 2019 novel coronavirus (COVID-19) effective with the next ICD-10-CM update on October 1. The CDC has released interim coding guidance to be used in conjunction with the current ICD-10-CM classification and the most recent ICD-10-CM Official Guidelines for Coding and Reporting[Read more]

 

FDA allows healthcare personnel to use industrial respirators during COVID-19 outbreak
Medical Laboratory Observer
The Food and Drug Administration (FDA) granted an emergency use authorization to allow healthcare personnel to use some industrial respirators during the COVID-19 outbreak in health care settings. [Read more] 
FDA seeks ‘right balance’ as it permits immediate use of coronavirus tests
MedTech Dive
Aiming to quickly expand testing capacity for the coronavirus as new cases climb and U.S. deaths are confirmed, the FDA said it will allow some laboratories to begin immediate use of new molecular diagnostics before regulatory review. Under the policy, outlined in an FDA guidance document effective immediately, labs still must submit an emergency use authorization request to the agency 15 business days after validating a new test. [Read more] 
Shortage of crucial chemicals creates new obstacle to U.S. coronavirus testing
STAT
The push to increase testing in the U.S. for the novel coronavirus that causes Covid-19 has hit a new stumbling block: shortages of key chemicals needed to start up and run the tests. [Read more]

 

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Are You Collecting What You Are Owed? Five Tips to Help Plug Revenue Leaks

With so much of healthcare reimbursement administered by contracts, expected net patient service revenue is often a function of the payment terms and conditions found in payer-provider contracts. In order to identify underpayments, wrongful denials and shortfalls, labs need an effective, automated contract management solution as part of their A/R processes.

Why Contract Management?

Regardless of laboratory type or size, every lab can benefit from automating the validation of every single claim against the contracted amount. A proper contract management solution helps to increase a laboratory’s revenue by identifying every dollar that should have been paid per provider contracts, supplying data for contract negotiations, powering accurate revenue forecasting, and decreasing manual work hours dealing with contracts; all while automating underpayments and denials to help achieve 100% collectability.

5 Tips to Help Plug Revenue Leaks

    1. Utilize contract modeling to build all net patient service revenue contracts, provider-to-client invoice-based contracts, all payment terms and conditions, for multiple years, including:

• Medicare/Medicaid schedules
• Government, third-party payer and client billing fee schedules
• Fee schedules for non-contracted payers
• Percent of charges
• Percent of Medicare
• Carve outs
• Outliers

    1. Create and maintain an actionable workflow to help pursue priority claims during pre-billing based on expected revenue versus total charge. Be sure to define payment variance rules and apply post adjudication to determine next steps.
    2. Validate charges to prevent charge master errors before a claim is submitted by configuring non-contracted payer rules to validate acceptance of patient co-insurance.
    3. Take advantage of cash flow analytics and variance reporting to calculate cash flow by payer, age of claim, and where the claim is in the revenue cycle. This analysis and reporting will help identify opportunities for maximum cash flow improvements in the revenue cycle. Variance reporting specifically will provide an immediate indicator of adjudication outside contracted rates.
    4. Simplify the collection and revenue recovery process by identifying underpayments to trigger automated appeal process.

Plug your revenue leaks by identifying and collecting on underpayments and wrongful denials by being armed with the correct contractual data to appeal and overturn them. Contact us today to learn how Quadax can help you collect what your lab is owed!

 

Surprise Billing Legislation: An Update and Ways to Mitigate Your Risk

Nearly 60% of insured adults have received a surprise bill on a healthcare service they thought was covered by insurance. And whether care or the provider is in-network, out-of-network or a mix of the two, 1 in 5 of these insured adults find it difficult to pay their deductibles.2 Why is this happening and what is being done about it?

Due in part to narrow provider networks, surprise bills can be the financial result of a patient receiving in-network care by an out-of-network provider, often the bill being the difference between the charged and the allowed amount of a service. These surprise bills can cause undue stress and have detrimental financial effects on the entire household, such as delayed payment on other household expenses, mounting credit card debt, and more. As such, state and federal legislations are responding in kind with laws around surprise bills.

 

STATE LEGISLATION

A number of states have enacted comprehensive laws to protect some patients from surprise medical bills, including California, Oregon, Illinois, Florida, New York, New Hampshire, New Jersey, Connecticut and Maryland. Additional states, including Texas, Colorado, New Mexico, and Washington, have passed laws expected to take effect this year. In essence, these laws are meant to protect consumers from surprise bills by limiting providers to the applicable in-network cost, setting a state payment standard, and/or establishing a dispute resolution process.Meanwhile, more than a dozen more states have enacted a limited approach to mitigate surprise bills.

 

FEDERAL LEGISLATION

Federal action is necessary to address certain aspects of surprise bills for people enrolled in self-funded plans due to the Employee Retirement Income Security Act of 1974, or ERISA.  Legislation is expected to be passed in fall of 2019.

Both state and federal initiatives can be summed up as:

  • All proposed legislation includes a ban on balance billing patients
  • Most legislation is specific to emergency and ancillary providers at this time
  • Many of the proposed state and federal bills include stipulations for using usual and customary rates as a basis for negotiation
  • Arbitration clauses included in many of the proposed bills is considered favorable to providers
  • Indexing against usual and customary rates seems to be included in more of the state initiatives

What can you do?

To help avoid and mitigate the risk of surprise bills, more and more hospitals and clinical laboratories are rethinking the patient experience and investing in tools to help provide pricing transparency on procedures and services, like testing. These tools utilize basic patient demographics (name, birthdate, address, insurance provider, etc.) to validate insurance coverage and eligibility, perform advanced benefit investigation to uncover plan-specific coverage details, assess prior authorization rules, and most importantly provide a patient’s expected out-of-pocket cost. Taking it even further, labs can identify a patient’s propensity and willingness to pay to help assess the need to offer financial assistance. This entire approach, called Patient Access Management, can help clinical labs and providers alike offer the transparency needed to empower a patient to make financial decisions regarding their care – perhaps the patient cannot afford the test so an alternative treatment plan has to be put into place. Patient Access helps to improve the patient experience in that the patient understands exactly what they will owe for the test – and no surprise bills. For a growing molecular lab, this can mean the difference between writing off bad debt and securing expected revenue.

To learn more about Patient Access Management solutions offered by Quadax and how they can help mitigate the risks of surprise bills and more, contact us today!

 

  1. http://www.norc.org/NewsEventsPublications/PressReleases/Pages/new-survey-reveals-57-percent-of-americans-have-been-surprised-by-a-medical-bill.aspx
  2. https://www.consolidatedcredit.org/infographics/medical-debt/#gref
  3. https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them/#

MIPS Scoring for Facility-based Pathologists: 3 Things You Need to Know

There are two pathways under the Quality Payment Program (QPP): MIPs and Advanced APMs. Unless you qualify as a participating clinician in an Advanced Alternative Performing Model, MIPS will be your default. MIPS has four weighted performance categories, identified below. This post will focus on Quality and Cost.

  •  Quality
  • Improvement Activities
  • Promoting Interoperability
  • Cost

As a facility administrator, navigating the requirements to be successfully compliant with MIPS can be confusing, especially for those CMS considers non-patient facing clinicians, like pathologists. Pathologists must optimize their participation in order to minimize the risk of losing out on bonus opportunities stemming from new and evolving CMS payment models. One of those models centers on the new policies of Facility-Based Measurements. As a facility administrator, what do you need to know?

1.  Definition of facility-based

Individual Facility-based clinician

•  Must have 75% or more of covered professional services in any of the following:

◽  Inpatient hospital (POS 21), or
◽  On-campus outpatient hospital (POS 22), or
◽  Emergency room (POS 23), and
◽ Have at least one service billed with POS 21 or POS 23

Facility-based group

•  At least 75% of MIPS-eligible clinicians billing under the group’s TIN are identified as facility-based.

Attributed to a facility with a Hospital VBP score

2.  Your facility-based status

The easiest way to determine and confirm your 2019 Facility-based status is to start with CMS by utilizing their online MIPS eligibility and look-up tool, found at https://qpp.cms.gov/participation-lookup. (You will need your HCQIS Access Roles and Profile System (HARP) credentials, Tax Identification Number (TIN) and National Provider Number (NPI).) This tool will also inform you if you are exempt from MIPS, in which case, you will not be responsible for MIPS reporting. If you are not exempt, the tool will provide you with any special status needed for reporting other than facility-based. The tool will also indicate your attributed facility if you have facility-based status.

If you are a facility-based pathologist or group, CMS will automatically assign you Quality and Cost scores for based on the attributed facility’s Hospital Value-Based Purchasing (HVP) program. CMS will assign these scores even if you are not a patient-facing clinician.

Facility-based pathologists should attest to Interoperability Activity scores separately to maximize their MIPS score. Facility-based pathology groups must attest to these scores separately from the facility in order to be assesses as a group and to maximize their MIPA score.

3.  Your potential 2019 MIPS performance

You can preview your Quality and Cost scores on the QPP website for estimated 2019 MIPS performance period, based on 2019 Hospital VBP Total Performance Scores (TPS) mapped to 2017 performance QPP data.

The 2019 MIPs scores will use 2020 Hospital VBP scores mapped to QPP data from the 2019 performance period. Note, scores between the preview and 2019 MIPS may change. How? There could be changes in the hospital to which the clinician or group is attributed. There could be updates to the HVBP TPS between 2019 and 2020 at the attributed hospital. Or, there could be updates to the distribution of MIPS quality and cost performance scores. The College of American Pathology suggests you may want to report on MIPS separately if you are not confident in your hospital’s VBP score as CMS will take the higher score from your reporting data.

The CMS recommends that eligible professionals check with the QPP Help Desk for more information on measures and the QPP.

QPP Help Desk Contact Information:

7:00 AM–7:00 PM CT Monday – Friday

email: QPP@cms.hhs.gov

Phone: 866-288-8292

*Adapted from Facility-Based Measurement: A Practical Overview, by Emily E. Volk, MD, MBA, FCAP (Aug 2019).