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Ask the Expert
| Author: Dr. Sheila Dunn |
| Article Date: 1/2/2007 |
Ask the Expert
In our Ask the Expert column, Dr. Sheila Dunn (AKA Dear Labby) dishes out accurate, concise and, sometimes, hilarious answers to your concerns about diagnostic testing, regulations and reimbursement for the physicians office. So, come on……ask the expert!
Email your questions to andyfillin.com
Medicare Reimbursement by State
Q. I recently bought a CLIA-waived influenza test kit so I could provide patients with a rapid flu diagnosis in my office. The company’s literature says that Medicare reimbursement is $16.76. Yet, when I received my first Medicare reimbursement it was $15.22. What gives?
A. Generally, companies provide Medicare’s “national fee limit” to prevent covering their product literature with payments from all 50+ Medicare carriers. Most Medicare carriers pay the national fee limit, which in the case of rapid flu tests is $16.76, but some state carriers are notoriously stingy and pay less. In the case of rapid flu tests, about 8 carriers pay less than this amount. The lowest is Arkansas, which pays $12.59; the remaining 7 thrifty carriers pay in the $14.50 to $16.00 range.
To help you find out the exact state payments for several common lab tests performed in physician offices, go to www.andyfillin.com.
Pay for Performance
Q. What’s the status on a federal Pay for Performance program?
A. The much maligned P4P program where Uncle Sam ties your payments to several quality care measures is marching forward with trial programs across the nation. About 800 solo or small to medium sized group practices in Arkansas, California, Massachusetts, and Utah were recently enrolled in P4P. These are in addition to the several thousands participating in acute-care hospitals and large, multi-specialty group practices.
This year, participating physicians will submit reams of paperwork on about 26 quality measures related to the care of patients with diabetes, congestive heart failure, and coronary artery disease.
The P4P program has Uncle Sam written all over it. In the first year, physicians will be paid for reporting the information—without regard to performance—to “help them become familiar with the quality measurement process”. Then, the rump rocket…ummm, reward comes in the second year when practices will be eligible to earn an annual incentive of up to $10,000 per physician and $50,000 per practice per year based on their performance on the quality measures.
My hunch is that P4P will go over about as well as the “Welcome to Medicare” exam did, which most physicians ignored, proclaiming that the additional income didn’t cover the paperwork burden.
The Tangled Web of CLIA Regulations
Q. I was considering bringing in CBC testing but one of my colleagues said that a recent CLIA inspection rivaled his last root canal. In a nutshell, what are the requirements?
A. Performing non-waived tests comes along with higher CLIA fees (a few cents per test), proficiency testing, written procedures and yes, inspections. It also requires that you “validate” new methods before you test patients, which takes a couple of hours over a period of two days. Instrument manufacturers are all over the board when it comes to CLIA support:
So, before buying a non-waived instrument, ask the manufacturer what CLIA-assistance they provide. While you’re at it, ask for free reagents to perform method validation.
PPO Fee Schedules
Q. Our large group practice is planning to bring in PSA testing to screen men over 50 for prostate cancer. When I approached our office manager to find out how much our top 5 PPO plans reimbursed for this test, she said she didn’t know because she didn’t have any of the fee schedules! When I looked incredulous, she said that none of our PPOs will share their fee schedule with us. This is unbelievable to me. Is she pulling my leg?
A. For the last decade, it’s been common practice for PPOs to tell physician offices that they weren’t allowed to see fee schedules. This allowed them to pay you whatever they wished, and sometimes nothing at all! At the end of their rope, 900,000 physicians filed a class action lawsuit against the 10 largest insurers for underpaying claims, denying claims or unfairly delaying payments. The physicians won and one provision of most settlements was that they had to share their fee schedules with their participating physicians. So expect Aetna, Cigna, Health Net, Humana, PacifiCare Health Systems, Prudential, United Healthcare and Wellpoint Health Networks to give you electronic access to your fee schedule. By the way, expect at least $25.60 reimbursement (the Medicare fee cap) for each PSA test.
SIDEBAR
The top 10 reasons why some doctors earn more than others include:
END SIDEBAR
Flu Bugs Reader
Q. I disagree with your advice in a previous ‘Ask The Expert’ column and think you underestimate the threat of avian flu. It’s much more serious than you suggest.
A. H5N1 has killed 154 people since 2003 but most cases occurred in 2006 when people contracted the virus from birds (flocks they kept in their backyard). Although there are no human cases yet in the US, health care facilities are being warned how to recognize cases of bird flu. The CDC released a list of symptoms of bird flu and encouraged those who experience any of the following to seek medical treatment immediately:
Glutaraldehyde Badges
Q. One of my employees is concerned that she’s being adversely exposed to our chemical sterilant and wants me to buy glutaraldehyde monitoring badges. Do all other physician offices provide these? Are they necessary?
A. Many physician offices that use a lot of scopes place glutaraldehyde soaking bins under a fume hood to protect workers from toxic vapors. If the absence of a fume hood, glutaraldehyde badges are often provided. I was in a urology practice a couple of weeks ago and almost gagged when I saw big uncovered metal soaking bins resembling fish poachers filled with glutaraldehyde in each procedure room. This is not good.
OSHA hasn’t had a permissible exposure limit (PEL) to glutaraldehyde since 1992, but most professional groups recommend that workers not be exposed to glutaraldehyde levels above 0.05 ppm.
Practices that use one or two soaking bins in a well ventilated area AND keep them tightly closed at all times except when employees are removing or inserting items, need neither a fume hood nor monitoring badges, since air levels of glutaraldehyde are certainly below recommended levels. If this doesn’t satisfy your employee, you can rent glutaraldehyde badges to do baseline readings to assure him that PEL’s aren’t being exceeded in your practice.
New TB Blood Test
Q. We have several employees that have had the BCG vaccine as adolescents and therefore their PPD tests are positive. I’ve been told that there’s a new blood test for TB that will solve this problem. Can you tell me about it?
A. The current skin test is archaic and a royal pain, literally. A new TB blood test, QuantiFERON®-TB Gold, is less subject to false positives and negatives than PPD skin testing. The QFT Gold test can be found at some health departments and most referral labs. Someday, a blood test will replace the PPD skin test, but this test is way too complex to be performed in a physician office, unless you have a med tech on staff.
Safety Needles on Pre-filled Syringes
Q. Are we exempt from switching to safety needles if we buy prefilled syringes that come without them?
A. No. Many meds in prefilled syringes are available with safety needles attached, many others aren’t. If you order ones that aren’t, OSHA regulations require you to add a safety needle to them before using them on patients.
Trust me on this. Recently, OSHA slapped a New Jersey nursing home with a $5000 fine for using prefilled syringes without add-on safety needles. It all began when a nurse was accidentally stuck after gesturing to another nurse who was holding a prefilled syringe without a safety needle (Can’t you just picture this?) The second nurse had used the pre-filled syringe without first attaching an add-on safety needle, and then failed to immediately place the unprotected needle in a sharps container.
Once OSHA got their foot in the door, the nursing home was also cited for not training staff on how to use add-on safety needles. As you know, OSHA requires annual retraining, so when a nurse testified that training had been so long ago that it simply didn't occur to her to look for and use the safety devices, fines began piling up.
In our Ask the Expert column, Dr. Sheila Dunn (AKA Dear Labby) dishes out accurate, concise and, sometimes, hilarious answers to your concerns about diagnostic testing, regulations and reimbursement for the physicians office. So, come on……ask the expert!
Email your questions to andyfillin.com
Medicare Reimbursement by State
Q. I recently bought a CLIA-waived influenza test kit so I could provide patients with a rapid flu diagnosis in my office. The company’s literature says that Medicare reimbursement is $16.76. Yet, when I received my first Medicare reimbursement it was $15.22. What gives?
A. Generally, companies provide Medicare’s “national fee limit” to prevent covering their product literature with payments from all 50+ Medicare carriers. Most Medicare carriers pay the national fee limit, which in the case of rapid flu tests is $16.76, but some state carriers are notoriously stingy and pay less. In the case of rapid flu tests, about 8 carriers pay less than this amount. The lowest is Arkansas, which pays $12.59; the remaining 7 thrifty carriers pay in the $14.50 to $16.00 range.
To help you find out the exact state payments for several common lab tests performed in physician offices, go to www.andyfillin.com.
Pay for Performance
Q. What’s the status on a federal Pay for Performance program?
A. The much maligned P4P program where Uncle Sam ties your payments to several quality care measures is marching forward with trial programs across the nation. About 800 solo or small to medium sized group practices in Arkansas, California, Massachusetts, and Utah were recently enrolled in P4P. These are in addition to the several thousands participating in acute-care hospitals and large, multi-specialty group practices.
This year, participating physicians will submit reams of paperwork on about 26 quality measures related to the care of patients with diabetes, congestive heart failure, and coronary artery disease.
The P4P program has Uncle Sam written all over it. In the first year, physicians will be paid for reporting the information—without regard to performance—to “help them become familiar with the quality measurement process”. Then, the rump rocket…ummm, reward comes in the second year when practices will be eligible to earn an annual incentive of up to $10,000 per physician and $50,000 per practice per year based on their performance on the quality measures.
My hunch is that P4P will go over about as well as the “Welcome to Medicare” exam did, which most physicians ignored, proclaiming that the additional income didn’t cover the paperwork burden.
The Tangled Web of CLIA Regulations
Q. I was considering bringing in CBC testing but one of my colleagues said that a recent CLIA inspection rivaled his last root canal. In a nutshell, what are the requirements?
A. Performing non-waived tests comes along with higher CLIA fees (a few cents per test), proficiency testing, written procedures and yes, inspections. It also requires that you “validate” new methods before you test patients, which takes a couple of hours over a period of two days. Instrument manufacturers are all over the board when it comes to CLIA support:
- Some provide nothing for method validation or CLIA;
- Some give written directions for method validation so you can do it yourself;
- Some give written directions, a CLIA Manual and a teleconsultation; and
- Some guide customers through the method validation process when they install the instrument and provide a complete fill-in-the-blanks CLIA Manual.
So, before buying a non-waived instrument, ask the manufacturer what CLIA-assistance they provide. While you’re at it, ask for free reagents to perform method validation.
PPO Fee Schedules
Q. Our large group practice is planning to bring in PSA testing to screen men over 50 for prostate cancer. When I approached our office manager to find out how much our top 5 PPO plans reimbursed for this test, she said she didn’t know because she didn’t have any of the fee schedules! When I looked incredulous, she said that none of our PPOs will share their fee schedule with us. This is unbelievable to me. Is she pulling my leg?
A. For the last decade, it’s been common practice for PPOs to tell physician offices that they weren’t allowed to see fee schedules. This allowed them to pay you whatever they wished, and sometimes nothing at all! At the end of their rope, 900,000 physicians filed a class action lawsuit against the 10 largest insurers for underpaying claims, denying claims or unfairly delaying payments. The physicians won and one provision of most settlements was that they had to share their fee schedules with their participating physicians. So expect Aetna, Cigna, Health Net, Humana, PacifiCare Health Systems, Prudential, United Healthcare and Wellpoint Health Networks to give you electronic access to your fee schedule. By the way, expect at least $25.60 reimbursement (the Medicare fee cap) for each PSA test.
SIDEBAR
The top 10 reasons why some doctors earn more than others include:
- Saw more patients and had larger practices
- Provided clinical lab, physical therapy, occupational therapy and imaging services in-house
- Evaluated and negotiated managed care contracts
- Saw more Medicare patients
- Were planning to buy an EMR system
END SIDEBAR
Flu Bugs Reader
Q. I disagree with your advice in a previous ‘Ask The Expert’ column and think you underestimate the threat of avian flu. It’s much more serious than you suggest.
A. H5N1 has killed 154 people since 2003 but most cases occurred in 2006 when people contracted the virus from birds (flocks they kept in their backyard). Although there are no human cases yet in the US, health care facilities are being warned how to recognize cases of bird flu. The CDC released a list of symptoms of bird flu and encouraged those who experience any of the following to seek medical treatment immediately:
- High fever
- Congestion
- Nausea
- Fatigue
- Aching in the joints
- An irresistible urge to crap on someone's windshield!
Glutaraldehyde Badges
Q. One of my employees is concerned that she’s being adversely exposed to our chemical sterilant and wants me to buy glutaraldehyde monitoring badges. Do all other physician offices provide these? Are they necessary?
A. Many physician offices that use a lot of scopes place glutaraldehyde soaking bins under a fume hood to protect workers from toxic vapors. If the absence of a fume hood, glutaraldehyde badges are often provided. I was in a urology practice a couple of weeks ago and almost gagged when I saw big uncovered metal soaking bins resembling fish poachers filled with glutaraldehyde in each procedure room. This is not good.
OSHA hasn’t had a permissible exposure limit (PEL) to glutaraldehyde since 1992, but most professional groups recommend that workers not be exposed to glutaraldehyde levels above 0.05 ppm.
Practices that use one or two soaking bins in a well ventilated area AND keep them tightly closed at all times except when employees are removing or inserting items, need neither a fume hood nor monitoring badges, since air levels of glutaraldehyde are certainly below recommended levels. If this doesn’t satisfy your employee, you can rent glutaraldehyde badges to do baseline readings to assure him that PEL’s aren’t being exceeded in your practice.
New TB Blood Test
Q. We have several employees that have had the BCG vaccine as adolescents and therefore their PPD tests are positive. I’ve been told that there’s a new blood test for TB that will solve this problem. Can you tell me about it?
A. The current skin test is archaic and a royal pain, literally. A new TB blood test, QuantiFERON®-TB Gold, is less subject to false positives and negatives than PPD skin testing. The QFT Gold test can be found at some health departments and most referral labs. Someday, a blood test will replace the PPD skin test, but this test is way too complex to be performed in a physician office, unless you have a med tech on staff.
Safety Needles on Pre-filled Syringes
Q. Are we exempt from switching to safety needles if we buy prefilled syringes that come without them?
A. No. Many meds in prefilled syringes are available with safety needles attached, many others aren’t. If you order ones that aren’t, OSHA regulations require you to add a safety needle to them before using them on patients.
Trust me on this. Recently, OSHA slapped a New Jersey nursing home with a $5000 fine for using prefilled syringes without add-on safety needles. It all began when a nurse was accidentally stuck after gesturing to another nurse who was holding a prefilled syringe without a safety needle (Can’t you just picture this?) The second nurse had used the pre-filled syringe without first attaching an add-on safety needle, and then failed to immediately place the unprotected needle in a sharps container.
Once OSHA got their foot in the door, the nursing home was also cited for not training staff on how to use add-on safety needles. As you know, OSHA requires annual retraining, so when a nurse testified that training had been so long ago that it simply didn't occur to her to look for and use the safety devices, fines began piling up.