"Anti-markup payment limitation"

[EBV]

Can't quite seem to understand this. Can someone dumb it down for me? thanks in advance.

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[djmd]

You are referring to the payment part of the anti-markup...?
It is complicated, and pointless....

Because the Site of Service Approach and Substantially All Approach
Clauses render the rule completely powerless against most pod lab set ups..

As long as the pod lab either does 75% of its work for the pod-masters or is in the same building as the pod-masters the rules don't apply.

 

[pathstudent]

Pod labs won't go away until pathologists quit taking those jobs.

I was talking to a pathologist who just had a new group or urologists move to his hospital. They wanted them to do the path for $20/container and they would be giving 12 containers per case. That sounds good but medicare pays about 40/container for an 88305 and good insurance pays a little more. So in essence the pathologists would be getting paid 40-50% and the urologists would be getting paid 50-60% for the PATHOLOGY interpretation. It is so absurd. But because so many pathologists are desperate type B people, there are plenty of people that will take that deal.

I Want to organize large number of family practice physicians to build a endoscopy/cystocopsy/prostate biopsy center, then we will hire a couple of desparate urologists/gastros to work there and we will pay them half of what we bill for their services. That is basically what they are doing to pathologists.

CAP needs to step it up to get this outlawed or the ABP need to greatly reduce the number of pathologists so there are not a bunch of broke ass desperate MFers that will take those suckass jobs.

I am just glad I going into academics so that I don't have to worry about this stuff, but still it pisses me off.

 

[thewebthsp]

This honestly sounds like Medicare fraud. To bill for another physician's work is prosecutable

 

[pathstudent]

^I think medicare doesn't allow GI groups to process their own specimens as I know one GI group had to send their medicare specimens to the local path group, but self pay and insured patients went to their own lab and their own tool of a pathologist.

Even though it is no different than fee splitting, it is made kosher by having the pathologist be an employee or a private contractor of the other physicians.

It is no different than if you take a job at a flow lab or reference lab for AP specimens. You generate a lot more than you get paid.

Who is really hurt by all this are the academic centers and hospital based pathologists. Instead of getting a mix of some well reimbursed specimens and some not as good ones (big surgical specimens), all the high paying ones are getting cherry picked.

The Lab Corps, Quests and PodLabs are finding a bunch of naive or desperate pathologists to sign out the high paying ones at 25 cents on the dollar.

I guess the other option is figure out how to be the guy that gets people to sign out stuff at 25 cents on the dollar and then pocket the 75 cents, but I am more interested in actually practicing pathology.

 

[yaah]

I am just glad I going into academics so that I don't have to worry about this stuff, but still it pisses me off.

Academics do have to worry about it though. I know of a few academic centers (some are small, granted, and maybe pseudoacademic) who lost a great deal of their biopsy revenue because the clinicians have all the leverage. The hospital needs their inpatient business and outpatient surgeries so they allow them to operate as independent contractors, and then of course they do their biopsies outside and send them elsewhere. Some hospitals and groups are respectable enough and big enough to thwart this at least someone, but most will suffer to some extent.

But yeah, I can't really figure out how any respectable medical organization can sit by while a group of physicians bill for someone else's work. I don't really think it's as simple as there being too many pathologists. I'm sure that's part of it. But there are also simply a lot of large labs who are always willing to take more specimens in and collect the technical component, and these labs facilitate this sort of thing.

It should be medicare fraud, but the rules are written with so many loopholes and vaguaries that it never matters. And government really doesn't care if some physicians are profiting more at the expense of other physicians - they only care if they are getting defrauded.

 

[thewebthsp]

Academics do have to worry about it though. I know of a few academic centers (some are small, granted, and maybe pseudoacademic) who lost a great deal of their biopsy revenue because the clinicians have all the leverage. The hospital needs their inpatient business and outpatient surgeries so they allow them to operate as independent contractors, and then of course they do their biopsies outside and send them elsewhere. Some hospitals and groups are respectable enough and big enough to thwart this at least someone, but most will suffer to some extent.

But yeah, I can't really figure out how any respectable medical organization can sit by while a group of physicians bill for someone else's work. I don't really think it's as simple as there being too many pathologists. I'm sure that's part of it. But there are also simply a lot of large labs who are always willing to take more specimens in and collect the technical component, and these labs facilitate this sort of thing.

It should be medicare fraud, but the rules are written with so many loopholes and vaguaries that it never matters. And government really doesn't care if some physicians are profiting more at the expense of other physicians - they only care if they are getting defrauded.

This is worth filing a class-action lawsuit... ACP et al. vs whoever is getting paid for others' work. Not only that put also a call to your friendly state attorney general