November 7 2012 Annual CCLA Conference Reimbursement Workshop 2012 Insurance Changes Bluecard Routing of claims to plan where specimen was drawn Must contract with each plan Paying patient for out of network claims ID: 804752
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Lâle White, CEO, XIFIN, Inc.November 7, 2012
Annual CCLA
Conference Reimbursement
Workshop
2012
Slide2Insurance ChangesBluecardRouting of claims to plan where specimen was drawnMust contract with each planPaying patient for out of network claimsAetnaTerminates contracted providers across US to reduce networkCignaReduced claims submission timeline 8/1/11 to 90 days (NY & TN 120 days, TX 95 days)
MedicareReduces timely filing to 12 months from 15-18 for 2012State MedicaidsIL Medicaid timely filing to 180 days from 12 mos effective 7/1/12NE Medicaid timely filing to 180 days from 12 mos effective 1/1/13
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Slide3Medi-CalFee Schedule 20% under Medicare at highest level10% Medi-Cal Provider Payment reduction- retro active 6/1/11Implementation of AB 1494 – New Rate MethodologyState Plan Amendment to CMS 9/28/1210% reduction upon approval of plan retro active to 7/1/12New rates targeted for 7/1/13
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Slide4MedicareMAC AwardsNoridianPalmetto GBA – RR MedicareMolDxCED2013 Reimbursement reduction – 5% on CLFS~3% (productivity impact & additional 1.75% cut)2% Rebasing of the fee schedule
TC Grandfather clause expires88305-TC rate reduced 52% G0416 Caps payments for biopsies at 10 or more unitsSaturation Biopsy code vs. Prostate Biopsy2013 Procedure Codes and ReimbursementCLFSNew physician interpretation code to be on PFS4
Slide52013 OIG Compliance Plan HighlightsMonitor Part B billing practices for NHsMedical Review of Provider claims with greatest CERT errorsHemoglobin A1C ordered more than one in 3 monthsScrutinize growth in laboratory Part B billing5
Slide6Moore’s Law
$3B
$5K
1999
2011
2005
Cost to sequence
genome
Clinical
Value
Cost Per Genome
Information Value
The Value Is the Information
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Slide8WSJ – Sources of the Next American BoomParadigm Changing Technological Breakthroughs Waiting in the WingsNanoculture Quantum ComputingExtreme miniaturization Cloud CrowdEase in sharing informationBig Data (i.e., monitoring every vital sign of sick patient every second)
Printing Dreams3D printing transforming manufacturingBolted to big data & nanotech to produce human organsSelf-HealthMonitoring devicesDisease ManagementHandheld DiplomasEmbedding education into the daily life
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Slide10Lâle White, CEO, XIFIN, Inc.Join the Conversation:
http://xifin.com/resources/blogs
Thank You
Slide11Industry Perspective – Uncertainty of Coverage & Uncertainty of Payment Rate Stifles InvestmentElimination of Stacking Codes Default to NOC
Lack:* Workflow automation* Coding flexibility* Coverage Clarity* Pricing Clarity
Investors require clarity on timelines and potential value of investment
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Slide12PWC National VC Association MoneyTree™ Report Q3 2011 Data Provided by Thomson Reuters
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Slide13PWC/National Venture Capital Association; MoneyTree™ Report, Data: Thomson Reuters
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Slide14Develop a Best of Breed – Stakeholder Collaboration to Establish Standards & Administrative Clarity14