Does anyone have a final comment or topic they want to raise?
Marc Kellner (Quadax): Regarding pay per performance, are smaller labs technologically capable of taking advantage of and being efficient in value-based models? Does it have as great an impact as it would on the hospital side?
Dr. Cardona (Wake Forest): The CAP has a quality clinical data registry that has roughly 1,800 pathologists currently using it to report for MIPS, the Merit-based Incentive Payment System, part of CMS’ quality payment program. It is a huge burden. When the registry was created, the goal and intent was to have interfaces that reduce the burden so the LIS can dump the information for the quality measures. In reality, health systems now are so cybersecurity risk-averse that we have maybe four or five practices that were able to get the interface. A bulk of them use their billing companies to help submit data on their behalf, but that’s still a burden on the practice from the work piece and in additional costs because they usually have to pay their billing company to report for them through the registry and to be part of the registry. It’s a financial burden for practices and they don’t have IT teams that can pull out all this data. The other bucket of participants are manually uploading Excel files or manually inputting cases, depending on the volume.
MIPS isn’t going away; QPP isn’t going away. This is bipartisan-supported legislation through MACRA [Medicare Access and CHIP Reauthorization Act]. But it will continue to evolve. CMS has already said the 2030 goal is for everyone to move from fee-for-service to a value-based care, take-a-risk model. How does pathology and laboratory medicine make that leap? We’re trying to figure that out now within the CAP. One step is the MIPS-value pathways, which will be opened up not just to small private practices but also large multispecialty group practices. CMS might require subspecialty group reporting. Right now, if you’re a pathology group in a large multispecialty group practice, you don’t have to do anything additional. If CMS requires subspecialty group reporting, which it said is a goal, now you’ve increased the burden to many more practices and pathologists.
Any other final comments?
Dr. Tuthill (Henry Ford): We talked about denials but not about reductions. That has been difficult for us to determine at Henry Ford. We throw the bill over the fence, we get paid, but we don’t really know what we got paid. So another wrinkle to the billing problem is that we get partial payment. Technologically, the more we can automate, the more we can use AI, the more the billing is clean, the better we’ll be able to perform in a pay-per-performance world because we will know what our revenues are. That has been a mystery to me for my 20 years of practice in pathology.
Marc Kellner (Quadax): There is significant opportunity to use contract data more intentionally, align fee schedules, compare remits against expected reimbursement, and equip billing teams with the insight needed to act quickly and accurately. Vendors like us automate this entire workflow so you can clearly identify what you were paid. When variances occur, we classify them and respond appropriately, enabling continuous improvement and ensuring performance tracks toward optimal reimbursement models.
Wendy Baehne (Telcor): People are using billing systems for nonbilling purposes like MIPS reporting. It’s where you’re getting your PAMA data. If you have a good system and as long as the data is there, we can get it out. To Dr. Tuthill’s point about knowing what the laboratory was paid, that goes back to the kind of system, how the data are stored, and what can be pulled out of your system, much of which ties into moving the technology forward.