Advocacy Update

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The CAP urged the Center for Medicare & Medicaid Services (CMS) to provide regulatory relief on several issues that affect pathologists, including prior authorization, rural health care access, evaluation and management (E/M) services, and timely regulation communication. Specifically, the CAP outlined the following strategies to reduce unnecessary administrative burdens for pathologists in a Request for Information August 12 response to the CMS:

Prior Authorization. The CAP asked the CMS to fix its prior authorization policy to prevent adverse patient events and reduce administrative burdens on pathology practices. The CAP wants the CMS to limit prior authorization requirements to essential laboratory tests, such as highly esoteric molecular/genomic testing, and to streamline prior authorization processes where possible.

Physician Burden in Obtaining Data. Pathologists participating in the Merit-based Incentive Payment System or MIPS need to report performance on quality measures. However, the CAP noted that it is difficult for pathologists to access data from hospitals’ electronic health records (EHRs) and laboratory information systems (LISs). The CAP encouraged both the Office of the National Coordinator (ONC) and the CMS to come up with solutions to improve the flow of information between hospitals EHRs, LISs, and registries. The CAP also urged the CMS and the ONC to develop a hold-harmless provision available to both owners and users of these data (hospitals, physicians, laboratories) for purposes of reporting MIPS reporting.

Coding and Documentation. The CAP made several recommendations to improve coding and documentation requirements for Medicare or Medicaid payment, including discontinuing “unlisted” coding practices, minimizing the impact of E/M revaluation,. and limiting the use of independent analytic contractors.

CMS Processes for Issuing Regulations and Policies. The CAP asked the CMS to provide regular updates in advance of ruling releases to inform stakeholders about anticipated timing. Moreover, the CAP requested and that the CMS be more predictable and transparent in issuing regulations and policies, including for the Qualified Clinical Data Registry self-nominations cycle and other MIPS policies.

The CMS used sub-regulatory guidance on several MIPS issues that the CAP would like to finalize through the formal notice-and-comment rulemaking process. 

Rural Health Care. The CAP urged the CMS to return to quantitative network adequacy standards for qualified health plans serving rural communities. Moreover, the CAP advised the CMS to revise its Medicare Advantage Organization network adequacy requirements by adding hospital-based specialties to the list.

Clinical Laboratory Fee Schedule. The CAP requested that the CMS include most hospital laboratories in the data collection used to calculate the 2018 Clinical Laboratory Fee Schedule Rates under the Protecting Access to Medicare Act. Therefore, the CMS can only then ensure the most accurate CLFS rates. The CAP also urged the CMS to provide continued access to laboratory tests for Medicare patients.

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Eligible pathologists who submitted their 2018 MIPS data through the Quality Payment Program (QPP) website can view their MIPS performance feedback and final score. The CAP recommends that pathologists check their scores to make sure they are correct.

The CAP asked the CMS to apply the Eligible Measure Applicability (EMA) process automatically to pathologists who did not submit a minimum of six quality measures, or did not have a high priority or outcome measure submitted in 2018. Through the EMA process, the CMS should automatically check whether these practices could have submitted additional measures. If the CMS discovers that no additional measures were available to the practice, the CMS should readjust the Quality category denominator, so that those practices are held harmless. If you discover that the CMS has not applied the EMA process to you or your practice, the CAP urges you to submit a targeted review request by the deadline of September 30, 2019.

The CAP also advocated and continues to support that pathologists and pathology practices should not be attributed to any cost measures. However, while reviewing their 2018 MIPS performance feedback, some pathology practices discovered that a cost category score attributed to their total score. Pathology practices should not have any cost measures attributed to their practices. The CAP encourages pathologists to review their performance feedback to check whether cost measures were included in the final score, and submit a targeted review request with the CMS.

Your 2018 MIPS performance will determine payment adjustments to your Medicare Part B payments in 2020 of +/- 5%. Preliminary MIPS feedback reports suggest that a MIPS score of 100% resulted in the maximum positive payment adjustment of 1.68%, which includes an exceptional performance bonus.

MIPS is a budget-neutral program, meaning that the money from negative adjustments obtained from poor performers are redistributed as positive adjustments to high performers. Presumably, due to the majority of MIPS clinicians performing very well in the program in 2018, the positive payment adjustments are not the highest +5% but rather modest. The exceptional performance bonus is not budget neutral, but rather from a separate pool of $500 million available to those MIPS clinicians and groups who performed above the Performance Threshold of 70 points.

Practices can access their 2018 MIPS scores by logging in to the QPP web site with their QPP login credentials.

Targeted Review

If you discover that the CMS did not apply the EMA process to your practice, and the CMS assigned a cost category score to you, or if you have other concerns about your preliminary score, the CAP urges you to request a targeted review from the CMS. Pathologists can request a targeted review until September 30, 2019. 

For more information, please refer to the 2018 Performance Feedback FAQs, 2018 Targeted Review Fact Sheet, 2018 Targeted Review FAQs, and the QPP Access User Guide or email CAP MIPS experts at

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For the fifth consecutive year, the CAP's Advocacy newsletter earned an Award of Excellence for 2019 in APEX’s newsletters category. This was the 31th annual APEX Awards for Publication Excellence.

APEX awards are based on excellence in graphic design, editorial content, and the ability to achieve overall communications excellence. Moreover, APEX's Award of Excellence recognizes exceptional entries submitted in dozens of individual categories covering print and digital media. The CAP’s advocacy newsletter also received APEX awards in 2015, 2016, 2017 and 2018.

For the 2019 APEX contest, staff submitted special breaking coverage of the 2018 final Medicare Payment Regulations. VIEW THE ENTIRE LIST OF 2019 WINNERS FROM THE APEX CONTEST.

The CAP’s Advocacy newsletter provides pathologists with news articles on topics ranging from federal regulation to legislation and local grassroots action. CAP members receive Advocacy Update, the official source for advocacy and policy news from Washington, DC, electronic newsletter issues on a weekly basis.

The CMS released of the proposed updates to the 2020 Medicare Physician Fee Schedule and the Quality Payment Program regulations on July 30. Therefore, the CAP has rescheduled its webinar to Thursday, August 29, at 3 PM ET/ Noon CT. Please review the latest Special Advocacy Update on the proposed 2020 Medicare Payment regulations.

Webinar presenters will be the Chair of the Council on Government and Professional Affairs Donald S. Karcher, MD, FCAP; Vice-Chair of the Council on Government and Professional Affairs and Chair of the Clinical Data Registry Ad-Hoc Committee Emily E. Volk, MD, FCAP; and Chair of the Economic Affairs Committee W. Stephen Black-Schaffer MD, FCAP.

During the 60-minute webinar, attendees will learn about updates to the 2020 Medicare Physician Fee Schedule and the Quality Payment Program regulations and its impact on pathologists. The CAP panel will also answer questions from attendees.

If you are unable to attend the live event, a link to view an archived recording of the presentation will be sent to all registrants following the webinar.

We appreciate your flexibility and look forward to your participation during the webinar on August 29.

Register today for the webinar.

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Join your fellow CAP members and test your advocacy knowledge with the new August Advocacy News Quiz. See how you measure up against your fellow pathologists on this month’s quiz and share your results. Good luck!

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