Anyone felt the effects of the Palmetto ruling?

[pathstudent]

I talked to a political action person from CAP and they said the Palmetto ruling which will cap IHC reimbursement at 20% for medicare patients is spreading across to the other medicare contractors for CMS. CAP said it is tough to block it.

While not every IHC stain ends up contributing to a case, cutting IHC to reimbursing only 1 in 5 will put us in a bad spot. I'll be forced to pay out of my own pocket to work up some cases properly or forced to not work them up to the present standards.

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[AZpath]

I have not heard anything yet.
So far Noridian and other have not acted. I am not sure why.

"Palmetto ruling which will cap IHC reimbursement at 20% for medicare patients"

I am not sure what you mean by cap. This is wide reaching medical necessity decision but there is no cap.

 

[LADoc00]

No but Palmetto is crap and is run by corrupt criminals so that doesnt surprise me.

 

[LADoc00]

Can you provide a link or something explaining what you are talking about please? Yah you Pathstudent. Im not seeing anything on the radar of anything of this sort. Also the whole 20% cap thing sounds absurd...not how that would even be implemented.

 

[Alteran]

I talked to a political action person from CAP and they said the Palmetto ruling which will cap IHC reimbursement at 20% for medicare patients is spreading across to the other medicare contractors for CMS. CAP said it is tough to block it.

While not every IHC stain ends up contributing to a case, cutting IHC to reimbursing only 1 in 5 will put us in a bad spot. I'll be forced to pay out of my own pocket to work up some cases properly or forced to not work them up to the present standards.

Hmmm....sounds like a lot of cases are going to be signed out as Atypical ___ Cell Population Identified, Defer (See Comment).

 

[pathstudent]

Can you provide a link or something explaining what you are talking about please? Yah you Pathstudent. Im not seeing anything on the radar of anything of this sort. Also the whole 20% cap thing sounds absurd...not how that would even be implemented.

This is based on a phone conversation and it was with a CAP lobbyist who wasn't a physician. It might his interpretation of Palmetto's LCD saying that only 20% of all stomach biopsies should need IHC. I do that Noridian will adopt the exact LCD shortly after OCTOBER 1. They cover Alaska, Arizona, California, Hawaii, Idaho, Montana, North Dakota, Nevada, Oregon, South Dakota, Utah, Washington, and Wyoming.

So far I have just read general comments like "the LCD places limits on special stains ordered by pathologists to assist them in making the correct diagnosis for the patient in areas such as breast cancer, gastrointestinal diseases, prostate disease, lung cancer, tumor profiling, cervical/GYN/bladder/kidney tumors, skin/soft tissue and peripheral nervous system lesion and bone marrow samples."


This is why I am asking if anyone has any experience with it yet, particularly those in North Carolina, South Carolina, Virginia and West Virginia where it has been in effect since March.

 

[LADoc00]

Mkayyyy. You are definitely reading this wrong or you have been given bad information. The actual Palmetto statement on overutilization and their "evidence" appears totally bunk and is actively being disputed by CAP. It is unlikely to mean much but does show that Palmetto is INSANE and hence why they lost the contract for intermediary out West.

 

[Adrian Cocot]

CGS, the MAC for Kentucky and Ohio released their final LCD the other day. They allude that unless you're a high-volume GI lab, you shouldn't be ordering ancillary stains on more than 20% of your biopsies. There's no mention of a cap, but it does seem like something that could be audited.

Guess that free 88313/88312 lunch is no more.

 

[pathstudent]

Mkayyyy. You are definitely reading this wrong or you have been given bad information. The actual Palmetto statement on overutilization and their "evidence" appears totally bunk and is actively being disputed by CAP. It is unlikely to mean much but does show that Palmetto is INSANE and hence why they lost the contract for intermediary out West.

The CAP disputed it and lost. They sought help from CMS in March who said they couldn't do anything about it.

http://www.cap.org/web/home/involve...ntentID=11074025&_adf.ctrl-state=jv5ak91vj_17

 

[LADoc00]

HOLY CRAPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP GD them!!

Okay screw this, lets begin the Revolución!!!!!

 

[LADoc00]

Ive put some more thought into this. The effect IF, which I highly doubt, these rulings were enacted and actually followed through on (doubt even more) would be a massive downward pressure on both junior pathologist and histotech income. I know there is massive spread of HT income from 13/hr in some rural places all the way to 50/hr in some big cities. I would expect this to draft downward significantly.

For new pathologists, I would expect incomes to be cut by 20% at least as practices start to lose money on certain cases when negative stain charges get rejected automatically. I think daily income benchmark could actually drop from a range of 700-1200/day to more like 500-800/day.

 

[Zarniwoop]

I have trouble getting a feel for what are the repercussions for individual pathologists.
Are you supposed to leave a job or not accept the limited opportunities out there because your employer insists on pre-ordering stains you "know" are of limited value.
Why not feel comfortable with these practices until the ruling actually comes down?

 

[Over9000]

Ive put some more thought into this. The effect IF, which I highly doubt, these rulings were enacted and actually followed through on (doubt even more) would be a massive downward pressure on both junior pathologist and histotech income. I know there is massive spread of HT income from 13/hr in some rural places all the way to 50/hr in some big cities. I would expect this to draft downward significantly.

For new pathologists, I would expect incomes to be cut by 20% at least as practices start to lose money on certain cases when negative stain charges get rejected automatically. I think daily income benchmark could actually drop from a range of 700-1200/day to more like 500-800/day.

I wouldn't do this job for 500 to 800 a day, not like it matters, since anyone can go find some Beijing-trained so-called pathologist to do the job for even less than that. Good thing I lived like a resident for that year.

Guess its a good lesson to learn: in order to have security in medicine you need 1. patients 2. limited numbers of practitioners and 3. specialized knowledge that is not easily automated or made into criteria.

 

[deleted314957]

The CAP disputed it and lost. They sought help from CMS in March who said they couldn't do anything about it.

http://www.cap.org/web/home/involved/advocacy/statline/statline-issue?contentID=11074025&_afrLoop=72941021817970#@?_afrLoop=72941021817970&contentID=11074025&_adf.ctrl-state=jv5ak91vj_17

I have learned that the term " being disputed by the CAP" ( like their silly alerts in stat-lines) has about as much significance as ones daily horoscope.

 

[AZpath]

If this goes nationwide it will have a greater impact than the cut in IHC payments by CMS ( restored this year ).
It is also hard to know how to justify and individual stain. So compliance will be a mess.

Palmetto's Dr. Jeeter (Dr. cheater) has been influential. All the prostate G codes were put forward by her.
I am sure she would advocate bundles for everything. It is a great way to cut current costs for CMS by 25% or more. It would be very damaging to the profession.

You might think yeah!, that annoying physicians office lab will go out of business.
The net effect will be consolidation and job loss. Quest and LabCorp love cheap labor.