Read the Latest Issue of STATLINE

Pathologists will be meeting with their congressional representatives and senators to urge support of the CAP’s legislative proposal to fix Medicare's flawed local coverage determination (LCD) process.

An Action Alert encouraging pathologists to schedule meetings with lawmakers was sent to CAP members ahead of Congress' August Recess. The CAP's LCD bill would ensure that coverage decisions are made by qualified health experts through a transparent process that is based on sound medical evidence. Reforms are necessary to ensure that LCDs do not impede a pathologist's medical judgment and deny patients access to medically necessary care.

In March of this year, Palmetto, the Medicare Administrative Contractor (MAC) for North Carolina, South Carolina, Virginia, and West Virginia implemented an LCD on special histochemical stains and immunohistochemical stains. The LCD places limits on special stains and IHC pathologists order to assist in making the correct diagnosis for the patient in areas such as breast cancer, gastrointestinal diseases, prostate disease, lung cancer, tumor profiling, cervical/GYN/bladder/kidney tumors, skin/soft tissue and peripheral nervous system lesion and bone marrow samples.

Since that time, identical or substantially similar draft versions of the LCD have been proposed by three additional MACs. If all are implemented, the impact of this highly flawed LCD would spread from four states to 20.

CAP members are attempting to fix the flawed LCD process by getting members of Congress to act. Pathologists are working to schedule meetings throughout August and until September 7.

The CAP has several resources available for members on this issue:

More updates on the CAP's advocacy to fix the Medicare LCD process will be published in future editions of STATLINE.

Back to the top

The Centers for Medicare & Medicaid Services (CMS) issued additional guidance in response to questions from the health care community related to the July 6 CMS-American Medical Association joint announcement allowing greater flexibility to physicians during the transition to ICD-10 diagnosis codes.

The guidance document states that while a valid ICD-10 code will be required on all claims starting on October 1, 2015, Medicare claims will not be denied or audited based on the specificity of the diagnosis codes used as long as they are from an appropriate family of codes, for the first 12 months after ICD-10 implementation.

In addition, physicians and health professionals who participate in CMS quality programs such as the Physician Quality Reporting System, the value-based payment modifier initiative, and meaningful use of electronic health records will not be penalized during the 2015 reporting year for failure to select a specific code, as long as they have selected one from an appropriate family of codes.

Read the entire CMS FAQ guidance document. And, read a CMS letter to physicians about the ICD-10 transition.

The CAP has additional resources about ICD-10 (login required) for pathologists. Access the CAP's archived webinar from May 21 on ICD-10. And, CAP members can email the College for their practice management questions.

After the October 1 implementation, practices will want to monitor the impact of ICD-10-CM transition on payments and claims denials and rejections, and identify and address problems and errors. The physician community, including the CAP, has expressed concern about the upcoming transition.

Back to the top

In order to promote standards of insurance network adequacy and ensure access to in-network physician specialists, the CAP and a coalition of hospital-based physician organizations proposed amendments to federal regulation addressing Medicaid Managed Care and Children's Health Insurance Program (CHIP) coverage.

The coalition detailed in a July 27 letter its concern for setting adequate insurance network standards and advocated for changes to the Centers for Medicare & Medicaid Services' proposed rule that includes the section "Availability of services, Assurances of Adequate Capacity and Services, and Network Adequacy Standards." The letter was signed by the CAP, American College of Radiology, American Society of Anesthesiology, and Society of Hospital Medicine.

The network adequacy section insufficiently ensures that patients enrolled in Medicaid contracted managed care organizations, pre-paid inpatient health plans, and pre-paid ambulatory health plans are able to access the services of in-network hospital-based physicians at participating facilities and hospitals.

The CMS contemplates use of "time and distance" as a standard to assess whether patients had reasonable access to in-network physician services. But the standard does not remedy the problem of health plans contracting with hospitals and facilities without a sufficient number of hospital-based specialist physicians at these facilities. State network adequacy standards in laws and regulations governing state licensed health plans have been woefully inadequate, the groups said.

"As a consequence, in the non-governmental payer market, patients have been involuntarily reliant upon out-of-network providers for hospital based services, with concomitant out-of-pocket costs for the patient that exceed deductibles, copayments, and coinsurance amounts that the patient would pay had the physician service been in-network under a contract with the health plan," the letter states. "The financial exposure of patients in this scenario can be attributed to the failure of state laws and regulations for network adequacy that has allowed health plans to market insurance products that do not provide robust networks of contracted physician specialists at in-network hospitals and facilities."

The CAP and physician groups believe the CMS should establish a paragon standard to promote a robust in-network provision of physician services at in-network hospitals and facilities regardless of governmental or non-governmental coverage. Doing so will protect patients, minimizing their costs for health care services in the commercial insurance market and in the state and federally sponsored health plan.

Read the full coalition letter.

Back to the top

The CAP and hospital-based physicians groups urged the Nevada Department of Insurance to ensure patients enrolled in approved health plans have adequate access to in-network physician specialist services at in-network facilities and hospitals.

"It is widely known and accepted that many health plans are now creating 'narrow' and 'ultra-narrow' networks that are intentionally designed to exclude providers and facilities from plan participation," the CAP and three national physician societies stated in a July 16 letter to the Nevada Division of Insurance. "The result of this intentional design of a benefit plan that is narrowly limited in provider and facility participation is to create network inadequacy and thereby increased potential for balanced billing of enrollees by non-participating providers."

Failure of health plans to establish adequate networks for hospital-based specialists subject patients to significant financial risk for out-of-network payments, the groups stated in the letter. The letter was signed by the CAP, American College of Emergency Physicians, American College of Radiology, and Society of Hospital Medicine.

The coalition urged the Division of Insurance to add two provisions to the regulation. First, health carrier networks should ensure sufficient numbers of participating providers offering hospital-based physician services, including pathology. Networks also must have an ongoing plan for providing network adequacy for its covered persons that includes a process to routinely monitor and assess access to services, including pathology and laboratory services.

"We believe both of these recommendations are essential to providing Nevada consumers and patients with high quality health care under the terms of any health plan seeking state approval," the groups said.

Read the full coalition letter.

Back to the top