tag:blogger.com,1999:blog-83343212718272177592026-08-03T12:39:27.248-07:00Ideas for or from an evolving healthcare systemBrucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comBlogger3454125tag:blogger.com,1999:blog-8334321271827217759.post-77419270706757343992026-08-03T11:24:16.565-07:002026-08-03T12:39:27.248-07:00

 CMS has a terrific database where you can see all codes (services) paid for any US laboratory.  Find it here.CMS also has a database for all CPT codes paid to Part B providers and labs, along with denial rates.  These tables are national, and are not provider specific.  But, if the code is a sole-lab PLA code, it's almost the same as provider specific.  Database here.I

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-36804072994930107622026-08-02T07:20:11.282-07:002026-08-03T12:36:05.226-07:00

 It's become almost a cliche' in the past decade that for many tests, Medicare coverage will occur ahead of most commercial insurance coverage.    Or, in clinical areas like minimal residual disease (MRD) or comprehensive genomic profiling (CGP; CMS NCD 90.2), Medicare coverage will be broader.This 15-page white paper was written entirely by Chat GPT, which was given only a few

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-83626034696463699402026-08-02T00:17:07.176-07:002026-08-02T16:14:50.758-07:00

 Daniel G. and the Rise of the LinkedIn Topic Expert in MRDhttps://www.linkedin.com/in/daniel-giner/This blog written by Chat GPT 5.6._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _LinkedIn has developed its own class of expert: the experienced industry participant who chooses a relatively narrow field, follows it almost continuously, and publishes enough commentary that readers begin to rely on

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-80869602228127088192026-08-01T16:04:52.026-07:002026-08-02T16:13:58.441-07:00

SUMMARY:The randomized phase III FIND trial integrated serial ctDNA methylation testing with protocol-driven CT imaging after colorectal cancer surgery. ctDNA-guided surveillance detected recurrence a median 3.9 months earlier and doubled curative-intent treatment among patients who relapsed (48.1% versus 23.6%). The study moves MRD beyond prognosis toward actionable surveillance, although

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-55631799377081197882026-08-01T15:11:00.958-07:002026-08-02T16:13:01.099-07:00

Josh Bowerman Maps the Rapidly Changing World of Clinical Genomics[This blog written by Chat GPT 5.6]Josh Bowerman has developed a distinctive body of commentary on clinical genomics, particularly oncology diagnostics, liquid biopsy, early cancer detection, comprehensive genomic profiling, and minimal residual disease. His articles are brief, visually polished, and generally published on LinkedIn

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-40507831826523742702026-08-01T14:49:47.746-07:002026-08-02T16:10:22.515-07:00

 Reading the Clinical Paper Commercially: Jack Kohler’s Methods to Bridge from Evidence to StrategyThe essay below is written by Chat GPT 5.6 after reading Kohler's web articles.  He's focused on biopharma, where one main pivotal trial usually is hugely influential in FDA decisions as well as coverage.  In diagnostics, VERY often, at least tests in novel areas, a whole sequence of

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-26172005144855819932026-07-31T10:03:02.844-07:002026-08-02T16:09:49.448-07:00

In May 2026, ArteraAI got FDA clearance for its computational pathology test for breast cancer.  FDA can take "weeks to months" to post its 20- to 30-page review packet - and the breast cancer review is now public.Artera AI Breast Cancer (NEW)See the K254114 product home page here;https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=K254115See the FDA's 28-page 510(k) review

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-52402333267715457372026-07-30T08:22:26.242-07:002026-07-30T08:24:55.803-07:00

A once-obscure CPT code, 87798, PCR for "other organism," exploded in usage to become the highest-paid molecular code in 2014.  During 2016, OIG reports have appeared and Medicare MACs rapidly began to slash payments for 87798.  See a representative Linked In article, here.As an experiment in AI writing - I briefly asked Chat GPT 5.6 to research 87798 at Linked In at elsewhere, get

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-39518850428178985262026-07-29T08:47:39.557-07:002026-07-30T10:27:23.866-07:00

 It's not out yet, but I'm seeing publicity for a new book on computational pathology, "Precision Pathology: From Pixels to Predictions."  Springer, here. The Amazon page says it ships November 4, 2026, here.See LinkedIn for one of the coauthors, Dr. Gu of Pittsburgh, here.If that's of interest, you may also like Rajni Toppo's essay, Human vs. Machine Judgment in

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-2202079651996413072026-07-28T13:31:43.849-07:002026-07-29T08:28:40.930-07:00

I was interested in how many LCDs the different MACs produce for lab diagnostics (MolDx, Novitas, Wellpoint Federal [former NGS MAC].)To my surprise, Chat GPT was able to follow instructions, search the CMS database for different parameters, and produce clean tables as output.  It could also volunteer insights along the way.You can see my long dialog with Chat GPT in a PDF, and also get

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-4218078619984414972026-07-28T11:00:08.201-07:002026-07-29T10:49:13.578-07:00

In the previous blog, I noted that CMS provides proposed OPPS/APC prices of Cat III codes that won't be effective for six months...and that don't even have public final code numbers.  (The same blog shows a comment letter from Valar that includes both the placeholder codes and real codes side-by-side).This is a Chat GPT explanation of how that particular bit of CMS magic works.###CMS Prices

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-29254043550232006192026-07-28T09:39:10.454-07:002026-07-28T10:03:05.135-07:00

 A lot of action on the digital pathology front.#1AMA RELEASES Dig Path CODESAfter the equivalent of a moratorium on new digital pathology codes, AMA began adding some to the Category III code set at February 2026 and May 2026 CPT meetings.   Those codes, while not active until January 2027, were published by AMA CPT on July 10.Find the AMA home page for Cat III here.  Jump

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-53600039836011767432026-07-27T09:19:47.503-07:002026-07-27T09:24:57.391-07:00

 I live in Hollywood; I love movies.   I've worked on CMS policy for twenty years; I love CMS policy.Here's a potential glitch where the two coincide.One of the top-rate films of the last couple months is TUNER, which covers romance, classical music, and ruthless dangerous criminals in one package. Plus it's set in NYC and contains several scenes in the modern underground 600-seat

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-7637908100999033532026-07-27T09:03:47.394-07:002026-07-27T09:03:47.395-07:00

 One of the most reliably interesting voices on Linked In is Joe Lennerz, successively of Harvard, Boston Gene, and now Natera.  Find his home page here, his Linked In postings here.In the last few days he's co-authored several important publications.   Kahles et al. appears in Health Policy & Technology, covers major problems arising from recent changes to IVR regulations

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-36140404927429884242026-07-26T20:32:11.523-07:002026-07-27T09:04:12.463-07:00

On July 14, the Washington Post had a scoop as the physician payment rule was released: it would contain an abrasive RFI going after AMA for its payment institutions, the CPT and the RUC.  (Here, here.)The WSJ had to take a time-out, but today we get a viewpoint (in WSJ) on Trump/RFK/AMA, and written by Kurt Miceli as an opinion piece.  Dr . Miceli is chief medical officer at the

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-44246384377006263192026-07-26T12:29:13.132-07:002026-07-26T12:42:56.940-07:00

 I had an MRI in June at a nearby hospital outpatient center.  When I log onto Medicare.gov/my/claims, I see the MRI code the hospital charged against, and the charge; $15,417.Medicare allowed $446.50, and Medicare Part B paid 80%, leaving $89.30 to my BCBS Medigap plan.  (Separate paperwork from them shows they paid the $89.30; I owed $0.)So the hospital charge-to-fee

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-81339132844124403292026-07-24T11:38:35.435-07:002026-07-24T11:39:33.944-07:00

Header:  Chat GPT rapidly answers general medical questions, here, slippage in colon cancer screening.##We had a screening colonoscopy in the family recently and I wondered:1) Of stool tests ordered, what percent get completed (e.g. mailed back)?2) Of positive stool tests, what percent get the indicated colonoscopy?Below is the direct output from Chat GPT.  I'm not taking it as gospel

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-13879884307945319682026-07-23T15:32:23.488-07:002026-07-23T15:32:23.488-07:00

 Header: A dissatisfied beneficiary can appeal his denied claim, OR, challenge the offending NCD or LCD as a whole. Let's see what's current on the CMS website.##AI CORNER##Medicare beneficiaries may challenge an LCD as unreasonable under 42 C.F.R. Part 426, but the process is obscure and procedurally demanding. Fifteen recent DAB cases show an active yet largely unsuccessful docket: all

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-87843068582012670382026-07-23T14:38:40.498-07:002026-07-23T14:42:06.338-07:00

 I'm such a CMS nerd that every year or two I used to scan the CMS Office of Hearings and Appeals (OMHA) for interesting cases.  (Back-when, there were some gems involving HeartFlow).I'm not sure if OMHA still posts as many cases.  But I asked Chat GPT to search CMS and the web for legal cases involving MolDx.  I show the results below.##AI Corner##The publicly available 

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-54914049300661799442026-07-23T14:12:11.321-07:002026-07-23T14:12:11.321-07:00

I mentioned several weeks ago that the NGS MAC (New England, New York, and MN-WI-IL) had begun referring to itself as WELLPOINT FEDERAL.  (While using "elevance" emails.)WELLPOINT FEDERAL is now showing up on CMS.gov websites, as below.Earlier:https://www.discoveriesinhealthpolicy.com/2026/06/the-mystery-of-wellpoint-federal-aka.html

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-45085242312737284772026-07-23T13:52:55.830-07:002026-07-23T15:10:13.224-07:00

In both its OPPS proposed rules, and its PFS or Part B proposed rules, CMS has proposed to drop AI-based or software-intensive lab diagnostic tests from the Clinical Laboratory Fee Schedule.  CMS says these services are not "CLIA tests" and do not require CLIA lab status.   In both rules, CMS preserves coding and payment pathways.  In OPPS, coding is the same, payment is

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-71999182294115513712026-07-22T10:23:44.501-07:002026-07-22T10:25:27.879-07:00

Here's one for your horizon scan.  FDA has posted draft guidance updating its policies for communications with payors, such as HEOR information.Here's my understanding.  FDA already had a guidance that covered marketed product (drug or device) communications with payors about 'health economics' that was not misleading.  Recall that the starting point for FDA-regulated

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-46047034478604962622026-07-21T16:33:06.867-07:002026-07-21T16:56:05.965-07:00

Do payers pay for AI?   Or do they assume AI-mediated savings, and deflation of prices?  Is one clinical area totally different from another in terms of AI financing and strategies?STAT just ran a three-part series on AI and reimbursement, with Medicare and other use cases.  Peterson Institute just released a 15pp on AI financing in healthcare.  And there are collateral

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-66164234639490844952026-07-20T19:29:45.004-07:002026-07-20T19:36:23.244-07:00

Header: An AI-generated 20-page white paper that surveys a decade of articles about payors and genomics.  Here's another adventure in current AI thinking and writing.  Chat GPT 5.6 surveyed 15 papers on payors and genomics, and for contrast, it also read 5 papers on payors and other medical industries. The report provides a general overview and key conclusions.  Trends

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-41052282101511428872026-07-20T12:20:13.278-07:002026-07-20T12:32:46.158-07:00

 You're probably seen press releases about the recent LabCorp $14M DOJ fine related to urine tox testing.There are some sources that go into numbing detail about the coding situations and the coding definitions and overlap.  First link is DOJ press release; second link is 11p court document.https://www.justice.gov/opa/pr/labcorp-agrees-pay-145m-resolve-false-claims-act-allegationshttps:

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.com