Newsletter
Salt Lake City, Utah Volume 7, Issue 1 March 1999
President's Message
By Susie Adams
It is my pleasure to introduce the new members of the Board. They are JoD Fontenot, Noel Ladle, Kathy Logan, and Susan Moesch, Treasurer. I appreciate all who ran, and invite each of you to become involved in a committee. I want to thank this year's board: Kathy Carlson, Paul Keoppel, Pat Martin, Ann Merkley, Jackie Nice, Dave Young, and Gloria Zuroff. I have never worked on a better board where each individual takes responsibility and projects are completed. Each Board member has put additional effort into the Chapter of the Year application. Besides the board, Chris Schumm has provided the section on Strategic Planning and Kathy Logan has spent hours editing and formatting the final document.
A special thanks to those retiring, Pat Martin, Ann Merkley, and Jackie Nice. Pat has saved an enormous amount of money for Spring Seminar. He had coordinated AV material from many facilities to avoid the high cost of rental. He has also helped with communications, piloting the first membership distribution through e-mail. Ann has kept an active membership committee going for 2 years and has agreed to continue with that committee. She has created a recruiting program to diversify the membership and spent hours at the CLMA booth. Jackie has remained active as Past President. She has maintained relationships with vendors and put together the strongest support ever for Power Breakfasts, The Zion Meeting, and Spring Seminar.
Leadership survey Results
I'd like to express my appreciation to all who have responded to the numerous surveys we have sent. The recent survey to assess the leadership effectiveness had approximately 38% return. 84% know who the officers are. 68% know the current board. 84% know how to contact the officers and the board. 64% know of the committees and their functions . 70-82% have been approached to serve as an officer, board member or a committee member. 89% said the chapter leadership represents their interest.54% have visited the national web site.46% have visited the new Utah web site. (Please check it out, it is full of the year's programs, newsletters, upcoming events with links to National, each local hospital's employment sites, etc. Paul has done an outstanding job and continues to update it regularly!)
Only 52% of the respondents know the chapter's goals.
The basis for our goal setting is the strategic plan. (Rather than a lengthy printing , I refer you to the Web Site http://users.sisna.com/paulk). Section V. Strategic Themes and Section VI. Strategic Objectives and Key Pursuits, cover the long term goals of the Utah Chapter. Each year at the Board Orientation we review the strategic plan and update portions as necessary. At that time we identify the primary objectives for the chapter's focus for the year. This year the three areas selected:
We have made progress in each area, but continue to emphasize these areas to improve.
I appreciate the opportunity to serve as Utah Chapter President this past year. It will continue to be one of the strongest chapters in the country with Dave Young as President and Paul Keoppel as President elect. The chapter continues to be innovative and we are all looking forward to the National Convention in Salt Lake City in 2003.
Spring Seminar
By David Young
Celebrating the 20th Century
Members of CLMA and USCLS celebrated the 20th Century, this
years theme, annual educational Spring Conference in Ogden Utah March 8 & 9.
The Conference afforded the participants the opportunity to select from a
variety of management, technical, and scientific topics along with a mixture
of fun, sight seeing, and relaxation.
The Conference attendees were welcomed by Ogden's own Mayor, Glenn J. Mecham followed by the Keynote address presented by a very humorous Weber State University professor, Dr. Michael Beard, who took us back to the good old days before FDA, CLIA, OSHA, and HIV. 170 participants registered for the Conference and selected from 16 workshops including the College of American Pathologists, "Advanced Inspector Training". Other well attended workshops included Roche Diagnostics Point of Care, ARUP - Dennis Monahan's Critical Thinking, Rayma Markland's QC Basics, Homicide Investigations Through Forensics, Investor's Guide to Retirement Planning, Panel Discussion - Recruitment and Retention Strategies for the 21st Century (CLMA members of the panel included, Steve Miller and Susan Moesch as moderator), and a tour of Ogden's notorious 25th Street.
The sponsorship from 29 Vendors this year was outstanding and their support continues to make this conference possible. I wish to personally thank all of the USCLS and CLMA members attending the conference and also those committee members who worked to make this year's Conference a success. Members who were not in attendance this year missed a very good opportunity to rekindle pride in their profession, network with old friends, learn new things, enrich management skills, and visit one of Utah's historic cities.
Health Care Policy
By Paul Keoppel
Negotiated Rulemaking
The negotiated rulemaking that has been in process since last July concluded for the most part in January. It's a slow, drawn out process, and tangible results are still probably two years away. That's 2001! No wonder CLIA '88 was not implemented until 1992. If it took private industry this long to react and make decisions we'd all be bankrupt. Some participants compared the meetings to be "like a 3 day dental appointment." So much for the humble editorial opinions. Now on to the facts.
The committee reached tentative agreement on 23 national coverage tests. They are: Blood glucose, Collagen cross-links, glycated hemoglobin/protein, thyroid testing, digoxin, all lipid testing, CBC, PTT, Prothrombin time, serum iron studies, alpha fetoprotein, CEA, flow cytometry, free PSA, PSA, HCG, urine bacterial culture, HIV(diagnosis), HIV(monitoring), AST, alkaline phosphatase, AST, fecal occult blood, GGT and hepatitis testing. This is a little different from the list currently used by the Utah carrier. The tests that are in bold above are tests that never were on the Utah list. The acceptable diagnosis codes have changed also. For example in the past the Utah LMRP for CBC had a list of 116 ICD9 codes. The new national policy for CBC takes a different approach and lists 11 codes that never will be payable for a CBC and 132 codes that are non-covered with limited exceptions. It says that Medicare will pay for any other codes not on the excluded list. For the tests that I have looked, the number of approved ICD9 codes seem to be longer. Take Prothrombin time for instance. The new national list contains 307 codes that Medicare will consider being medically necessary. It also lists 39 codes that will never be considered necessary. The policy itself is over 20 pages long. If all of the policies are this big it will result in a book of over 400 pages. Light reading for sure! If there is a bright side to all of this, it is the fact that these are national policies and the variation from state to state will cease. However, local Medicare contractors still have the permission to come up with their own policies for a test that they feel is being abused if it's not one on the national list.
Time line
The proposed rule is expected to be published in the Federal Register in May of this year. The final rule should follow this fall. The effective date will be 12 months from the publication of the final rule. There may be a grace period of an additional 12 months for any party required to make systems changes. So, like we said at the top of this column, that puts the date between October 2000 and December 2001.
Key Provisions of Draft Consensus Agreement
HCFA to discuss PAP Smear Rate
HCFA had a meeting to discuss pap smear pricing with laboratory interests last month. The agency is expected to use it's "inherent reasonableness" authority to issue a proposed rule later this year that would increase payment for manual Pap smears beginning next year. One first must question if anything coming from Medicare has "inherent reasonableness", but we digress. The inherent reasonableness authority requires that affected parties be consulted when a proposal to increase or decrease payment for a service would result in a change of 15% or more annually. The notice must be published in the Federal Register for public comment. HCFA promised to publish the payment suggestion for Pap Smears in the Federal Register within the next 30-60 days. This would make it possible for a comment period and having the fee in effect when the 2000 lab fee schedule is published later this year. The College of American Pathologists has asked for an increase payment for pap smears to the $13 to $17 range. As you know, last year there was legislation in congress to increase the pap smear payment to $14.60. While this bill failed, it did get the attention of Congress. Congress did include in the 1999 fiscal budget bill language urging HCFA to increase the pap smear payment. This sense of Congress statement noted the "large disparity" between Medicare's current payment rate for a manual screening Pap smear and a clinical laboratory's typical cost to perform the test.
Source: CAP Statline and G2 Reports
Medicare laboratory Copay?
The National Bipartisan Commission on the Future of Medicare is suggesting a 10% copay for laboratory services covered under traditional Medicare fee for service. This could cause a big headache for labs because the copay would be relatively small for most tests and would cost more to collect than they are worth. Labs could not ignore the copay requirement and give up the 10 percent because routine waiver of copays is illegal under the anti-kickback laws.
We'll follow this one closely.
Medicare Part A and Medical Necessity
By Paul Keoppel
Your hospital based laboratory is billing outpatient Medicare and is getting paid. Everything is rosy, right? Don't count on it. Billing Medicare for hospital laboratories is doubly confusing. Hospital laboratories must bill outpatients to the Medicare Part A Intermediary. The intermediary pays the hospitals from Part B funds, using Part B billing rules. Medicare's latest mode of operation with Part A laboratories is to pay first and fine later. The Part B rules are where all of the Local Medical Review Policies (LMRP) are published. These policies apply to both Part A and Part B payers. There is a problem however. The intermediary accepts bills on a UB-92 form and a carrier accepts bills on a HCFA 1500 form. The carriers (Part B) have programed their computers to screen lab bills for medical necessity using the LMRP criteria. This results in denials for lack of medical necessity. The Part A intermediary has no such edits in their computer, at least in Utah. This creates problems for laboratories.
As a laboratory manager you need to be privy to the information published by both the carrier and the intermediary. The newsletters are usually sent to the hospital billing department. Ask to see copies of them. The Utah Medicare Intermediary has published two articles in their Medicare Communique during the past year. In June of 1998, on page 2 and 3, there is a question and answer discussion on laboratory billing and medical necessity. Three of the questions are reprinted verbatim here.
Q. If a diagnostic test had a medical necessity policy and does not meet the guidelines and is billed without any remarks or notations, is this considered okay?
The January 1999 Medicare A newsletter contains a stiff warning about the False Claims Act. It states in part, "Through the False Claims Act, civil liability is imposed on any person or entity that submits a fraudulent claim for reimbursement to the federal government.--The False Claim Act is applied not only to those who intentionally commit fraud, but also to those who practice 'willful blindness.' This may be used when someone acts in deliberate ignorance or reckless disregard of the truth, i.e., the person 'should know'."
If your hospital laboratory is not checking the claims against the limited coverage test list you are placing the hospital at considerable risk to action from the OIG. Even though it is the physician that orders the testing, it is the entity billing, YOU, that is liable for a false claim. HCFA can also go after the physician if an audit reveals a trend of ordering that Medicare considers medically unnecessary testing.
Power Breakfast Review
By Gloria Zuroff
Rand Kerr, Assistant Administrator, St. Mark's Hospital
January 14, 1999
"The Healthcare Environment, Winds of Change"
Changes in Healthcare seem to be constantly surrounding us and have affected all of us in Utah. Rand's presentation led us closer to understanding Market Dynamics, the Perpetual Pendulum, Hospital Essentials, and Communication Needs.
In the past healthcare was delivered where we were paid a fee for service. (Remember those days?) We were then led into Managed Care. Looking ahead Rand discussed the dynamics in our market such as "focused factories", disease focused and incentive driven community care facilities, and always a new paradigm with the evolution of the market.
We all have been affected by the Perpetual Pendulum in healthcare with the Supply/Demand Curve, Cost/Quality, Integrated/Specialized, Out-Source/In-House testing and Tax Exempt/Investor Owned. As we understand the shifts and changes in healthcare we have also understood that the pendulum does change as various needs are met.
Rand lead us into an understanding of quantifying quality by reviewing and understanding Outcomes Data. The Economic indexes of revenue vs. collections, ROI, EEOB, EBDITA are part of our everyday lives in management and healthcare today.
The Healthcare Environment is constantly changing. Any variation from a routine can be stressing. Rand explained that healthcare changes in the past were slow and infrequent. In the future changes will occur at an unprecedented rate. We are feeling that now with constant need to address issues and change our delivery of healthcare as necessary. Entities that adapt and embrace change will succeed and those entities that resist and fight change will be overtaken by the market. We all must work together as we share information, resources and develop trust and continue to deliver some of the best healthcare in the country.
Member Survey Results
Thanks to all of you who responded to the member survey last January. The board will use the results to better serve the members.
What are we doing well?
Over 80% of respondents felt that the newsletter had good content and was of the right length and frequency. The power breakfasts were marked as being good or excellent by over 90% of you. It was unanimous on the Salt Palace for spring conventions- 100%. The meeting site at Zion had good or excellent scores by 81% of respondents. The most popular day and time to hold Power Breakfasts was Wednesday at 7:30am in Salt Lake City.
What do we need to work on?
Timely meeting announcements received poor marks by 40% of members. The nomination of members to run for office also was marked down by 40% of respondents. Does the Health Care Policy Committee keep me current was answered 50/50 by respondents.
Licensing of technologists:
65% of members responding support the state licensure of laboratory personnel performing either moderate or high complexity testing as classified by CLIA. Conversely, 67% of respondents do not support the licensing of personnel performing waived testing.
Examples of topics members requested be covered in future meetings.
Understanding Healthcare finance
HCFA and OIG updates
Reimbursement and time management
Dealing with insurance companies
Insurance maze
Lab requirements from a managed care perspective
CPT coding and reimbursement
How to deal with Medicare
Compliance and coding
What's in the email today?
A man runs into the vet's office carrying his dog and screaming for help. The vet rushes him back to an exam room. The vet examines the still, limp body and after a few minutes tells the man that his dog is dead. The man is very upset, not willing to accept this, and demands a second opinion. The vet goes into the back and comes out with a cat. He puts the cat down next to the dog's body. The cat sniffs the dog and walks all around the dog. Finally, the cat looks at the vet and meows. The vet looks at the man and says. "I'm very sorry, sir, but the cat thinks your dog is dead too." The man is still unwilling to accept the loss of his faithful companion and friend of all these years, so he asks for another opinion. The vet goes in the back and gets a black Labrador retriever. The dog sniffs the body, walks around the body, and finally looks at the vet and barks. The vet looks at the man and says, "I'm sorry, but the lab thinks your dog is dead too." The man, finally resigned to the diagnosis, thanks the vet and asks how much he owes. Th vet says "$650." "$650 to tell me that my dog is dead!", exclaims the man.
"Well," the vet replies, "I would have only charged you $50 for my initial diagnosis. The additional $600 is for the cat scan and the lab tests."
Compliance Update
By Paul Keoppel
OIG releases new fraud alert
The HHS Office of Inspector General published a new Fraud Alert in the January 12 Federal Register. The OIG is concerned with physicians ordering home healthcare and durable medical equipment, prosthetics, and other supplies. The Fraud Alert stresses that a physician may be liable under the federal False Claims Act for providing false information, even though no benefit flows back to the physician.
If your laboratory is having difficulty in convincing physicians to provide medical necessity information, this alert may help your argument.
OIG Advisory Opinion on discounted services
The OIG from HHS released advisory opinion 99-2 on March 4, 1999. The opinion addresses discounts provided to skilled nursing facilities(SNF) by ambulance companies. Although the advisory applies only to the specific question asked, it provides some of the government's current thinking on discounts in general. Because nursing homes have now switched to prospective payment for Part A services but not the Part B services, there are practices that the OIG may consider kick-backs for nursing homes. The advisory says that discounts on services to residents covered under Part A, but not on services to residents covered by Part B or by other payers might violate both the anti-kickback law and the Medicare prohibition against "substantially in excess" charges. While the anti-kickback statute contains a "safe harbor" for discounting, the OIG concluded that the discount to SNFs does not fall into a safe harbor. The advisory states,
"The statutory exception for discounts, as implemented by the regulatory safe harbor, does not protect price reductions-like those at issue here-offered to one payer but not offered to Medicare or Medicaid...We are aware of cases where laboratories offer a discount to physicians who then bill the patient, but do not offer the same discount to the Medicare program. In some of these cases, the discount offered to the physician is explicitly conditioned on the physician's referral of all of his or her laboratory business. Such a 'discount' does not benefit Medicare, and is therefore inconsistent with the statutory intent for discounts to be reported to the programs with costs and charges reduced appropriately to reflect the discounts."
The OIG list of discounting practices that are particularly suspect
The advisory opinion is on the OIG web site at www.dhhs.gov/progorg/oig.
FBI press release, Oct 1998
"The FBI is making far greater use of undercover investigations to crack down on large-scale health care fraud. Those who carry out health care fraud schemes should be fully aware that the FBI has made investigation of these crimes a priority. The FBI supports stringent prison terms and fines as well as the recovery of funds that have been obtained illegally. Most health care professionals and firms provide honest treatment and billing but they unwittingly co-exist with significant illegality in the health care field, including sophisticated criminal enterprises. The health care system represents one-seventh of the nation's economy, and organized criminal enterprises have penetrated many segments of the health care field. The FBI views the problem with enormous concern. It is one of the FBI's top national priorities and we have established dedicated health care fraud squads in many of our largest field offices. There has been a gradual and effective buildup of FBI resources dedicated to combat health care fraud, from the equivalent of 112 special agents in 1992 to 356 in 1997. In that same period, the FBI's health care fraud caseload increased from 591 cases to 2,582 cases."
"The Department of Justice in coordination with the FBI has placed major emphasis on fund recoveries in health care fraud cases. Here are some examples:
The complete text of this press release can be obtained on the Internet at www.fbi.gov/pressrel/medweb.htm
Education
By Kathy Carlson
Join your colleagues in Dallas and discover why the CLMA Annual Conference and Exhibition is the premier educational event for laboratory and clinical systems professionals. More than 90 Breakout Sessions focus on ten educational tracks to provide in-depth examination of the following areas:
Make your reservations early!
Check out the latest conference news @ www.clma.org and then visit the Utah Chapter website!
Mark Your Calendars !
April 14, 1999: Montana CLMA Meeting
May 10-11: War College - New Orleans
May 13, 1999: Powerbreakfast
"Clinical Integration and Care Processes - The Laboratory's Role" .
Join your colleagues as Dr. Gregory Schwitzer from Intermoutain Health Care discusses the future of Utah healthcare delivery systems.
Continuing Education Opportunities: