Lâle White, CEO, XIFIN, Inc. November 7, 2012 Annual CCLA Conference Reimbursement Workshop 2012 Lâle White, CEO, XIFIN, Inc. November 7, 2012
Insurance Changes Bluecard Aetna Cigna Medicare State Medicaids Routing of claims to plan where specimen was drawn Must contract with each plan Paying patient for out of network claims Aetna Terminates contracted providers across US to reduce network Cigna Reduced claims submission timeline 8/1/11 to 90 days (NY & TN 120 days, TX 95 days) Medicare Reduces timely filing to 12 months from 15-18 for 2012 State Medicaids IL Medicaid timely filing to 180 days from 12 mos effective 7/1/12 NE Medicaid timely filing to 180 days from 12 mos effective 1/1/13
Fee Schedule 20% under Medicare at highest level Medi-Cal Fee Schedule 20% under Medicare at highest level 10% Medi-Cal Provider Payment reduction- retro active 6/1/11 Implementation of AB 1494 – New Rate Methodology State Plan Amendment to CMS 9/28/12 10% reduction upon approval of plan retro active to 7/1/12 New rates targeted for 7/1/13
2013 Reimbursement reduction – 5% on CLFS Medicare MAC Awards Noridian Palmetto GBA – RR Medicare MolDx CED 2013 Reimbursement reduction – 5% on CLFS ~3% (productivity impact & additional 1.75% cut) 2% Rebasing of the fee schedule TC Grandfather clause expires 88305-TC rate reduced 52% G0416 Caps payments for biopsies at 10 or more units Saturation Biopsy code vs. Prostate Biopsy 2013 Procedure Codes and Reimbursement CLFS New physician interpretation code to be on PFS
2013 OIG Compliance Plan Highlights Monitor Part B billing practices for NHs Medical Review of Provider claims with greatest CERT errors Hemoglobin A1C ordered more than one in 3 months Scrutinize growth in laboratory Part B billing
The Value Is the Information Moore’s Law $3B $5K 1999 2011 2005 Cost to sequence genome Clinical Value Cost Per Genome Information Value
WSJ – Sources of the Next American Boom Paradigm Changing Technological Breakthroughs Waiting in the Wings Nanoculture Quantum Computing Extreme miniaturization Cloud Crowd Ease in sharing information Big Data (i.e., monitoring every vital sign of sick patient every second) Printing Dreams 3D printing transforming manufacturing Bolted to big data & nanotech to produce human organs Self-Health Monitoring devices Disease Management Handheld Diplomas Embedding education into the daily life
Thank You Lâle White, CEO, XIFIN, Inc. Join the Conversation: http://xifin.com/resources/blogs
Industry Perspective – Uncertainty of Coverage & Uncertainty of Payment Rate Stifles Investment CPT code stacks Lack: * Payor Clarity NOC Codes Lack: * Workflow automation * Coding Flexibility * Pricing Clarity * Coverage Clarity Palmetto MolDx PTI/Z Codes Lack: * Coding Standards * Coding flexibility once stacking codes are gone MoPath and MAAA codes * Expedited process Investors require clarity on timelines and potential value of investment Elimination of Stacking Codes Default to NOC Lack: * Workflow automation * Coding flexibility * Coverage Clarity * Pricing Clarity
PWC National VC Association MoneyTree™ Report Q3 2011 Data Provided by Thomson Reuters
PWC/National Venture Capital Association; MoneyTree™ Report, Data: Thomson Reuters
Develop a Best of Breed – Stakeholder Collaboration to Establish Standards & Administrative Clarity AMA CPT Agile/Adaptable Flexible/Granular Clarity Confirmation of Clinical Validity (CLIA or FDA) Non proprietary NIH Registry Transparency Comprehensive directory of services Open on-line access Alignment of missions Data Sharing MolDx Centralized Technical Assessment Clinical Utility Standard process Objective criteria Equitable Pricing