UPDATES

July 1, 2013  

Medi-Cal 10% Cut and Clawback   

The Medi-Cal 10% provider rate cut that is likely to be retroactive to June 1, 2011 is running out of legal options to stop the implementation. Prior injunctive relief to block its implementation in federal court has been reversed in the Ninth Circuit Court of Appeals. Though there has been support in the Legislature on a bi-partisan basis to eliminate the cut and prohibit retroactive recoupment to claims paid since June 1, 2011 the Governor has been unwilling to eliminate the reduction. He believes that the cuts made in prior years have to be retained to keep the budget balanced.

As of this writing it is likely that there will be initial implementation of a 10% rate reduction, perhaps on September 1st , and then a later effort to recoup the now overpayments going back to June 1, 2011 by taking an additional 5% of the individual provider amount in checkwrites on a monthly basis. The specifics are yet to be finalized and we will keep you informed.  

Medicare Denials Based Upon Patient Being Classified as Hospital Patient on DOS    

We have continued to hear complaints from some pathology groups that are getting Medicare denials for global charges for anatomic pathology services where the place of service is a free standing clinical lab. Claims for biopsies and other services are sometimes denied  with a 96- non-covered charge with a remark code of N70, "Consolidated billing and payment applies". The charge is denied because the Palmetto system shows that this patient was a hospital outpatient or in patient on the date of service. It could be that the patient did get another service from a hospital lab or other service on that same day.

There is an effort underway to get the policy on Place of Service edits to either not be applied to pathology services or to verify the patient information in the Palmetto system. In the meantime you should appeal these denials and you might consider aggregating the claims. The impact is sporadic and impacts various practices differently.  

Doctors Company Advisory to Pathologists on Avoiding Malpractice Liability     

The Doctors Company is the endorsed malpractice insurer for the CSP. Dr David Troxel, the Doctors Company medical director, is a pathologist and has provided us with a copy of his article on metastatic squamous carcinoma.  We have reprinted below a copy of his article for your consideration.

Doctors Company Advisory to Pathologists on Avoiding Malpractice Liability     

The Doctors Company is the endorsed malpractice insurer for the CSP. Dr David Troxel, the Doctors Company medical director, is a pathologist and has provided us with a copy of his article on metastatic squamous carcinoma.  We have reprinted below a copy of his article for your consideration.

Metastatic Squamous Carcinoma misdiagnosed as Branchial Cleft Cyst

The misdiagnosis of metastatic well-differentiated squamous carcinoma as a branchial cleft cyst is an on-going cause of pathology malpractice claims. I've reviewed approximately 15 such claims between 1995 and 2010.

The patients are typically young males (ages 30 to 45) in an age group where "cancer" is not the first diagnostic consideration. In addition, branchial cleft cyst is often the clinical diagnosis, contributing to the pathologists "mindset" when examining the slides. At the time of misdiagnosis there is usually no known primary carcinoma - contributing to the failure to consider a metastasis. In most cases an occult primary is subsequently found in the oropharynx or nasopharynx. The squamous carcinomas are cystic and usually well-differentiated - features further contributing to the misdiagnosis of branchial cleft cyst, particularly in a young patient.

Recommendations:

1.)  Do not make a diagnosis of branchial cleft cyst without first considering the differential diagnostic possibility of metastatic well-differentiated, cystic squamous carcinoma - regardless of patient age and clinical diagnosis.

2.)  Look carefully for cytologic atypia in the lining squamous epithelium. If present, consider immunostains for HPV. Alert the clinician to the need for thorough work-up to exclude an occult primary in the head or neck - and particularly at the base of the tongue or tonsillar fossa, since HPV+ cancers arising in these locations may have cystic metastases to cervical lymph nodes.