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The CAP, along with laboratory industry groups, requested a meeting with the Government Accountability Office (GAO) to discuss strong disagreements with a recent GAO report concerning new Medicare payment rates for clinical laboratory services as mandated by the Protecting Access to Medicare Act (PAMA).

In the report, the GAO stated that PAMA could cost Medicare billions of dollars, rather than save money as lawmakers intended. The CAP, as well as the industry groups, said the report made flawed and dangerous assertions, which may suggest that initial PAMA reimbursement reductions should have been more severe.

In a February 11 letter to the GAO, the CAP, AdvaMedDx, American Clinical Laboratory Association, the National Independent Laboratory Association, and the Point of Care Testing Association formally objected to the report. The groups further stated they should meet to review why the GAO has misunderstood the implications of PAMA.

In the letter, the groups also disagreed with the GAO over suggestions related to panel tests. “The discussion on panel test billing demonstrates a fundamental misunderstanding by GAO of actual, real-world billing practices of clinical laboratories,” the letter said. Another area where the groups strongly disagreed with the report was the GAO’s recommendation for the Medicare agency to use average pre-2018 Medicare rates as the benchmark when phasing in payment reductions.

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The Centers for Medicare & Medicaid Services (CMS) proposed coverage with evidence development for CAR T-cell therapy, the new form of cancer therapy that uses a patient’s own immune system to fight the disease, on February 15. Since pathologists are involved in the initial diagnosis and subsequent treatment plans for cancer therapy, the coverage proposal poses some issues that include how patients will be monitored after treatment.

The proposed National Coverage Determination policy would require Medicare to cover the CAR T-cell therapy nationwide when it is offered in a CMS-approved registry or clinical study, in which patients are monitored for at least two years post-treatment. The hospitals administering CAR T-cell therapy, whether through inpatient or outpatient care, must participate in the CMS-approved registry that collects data on patient outcomes and characteristics. Data from the registries will then be used to identify patients that benefit from CAR T-cell therapy and inform future coverage decisions.

Currently, there is no national Medicare policy for covering CAR T-cell therapy, so local Medicare Administrative Contractors will have full discretion on whether to pay for it.

The CAP sent a letter to the CMS on June 15, 2018 expressing support for the initial coverage of two FDA-approved CAR T-cell therapies. However, the CAP did express concern that any attempt at a national coverage policy to standardize these CAR T-cell services may fail to recognize the individual care services provided by physicians, like pathologists, and other health care professionals. Pathologists are involved in the initial cancer diagnosis as well as monitoring the cancer recurrence during patient treatment. The CAP will engage with the CMS on these concerns by March 17.

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With health insurers narrowing networks of contracted physicians to shift health care costs onto patients through unanticipated medical bills, the CAP advocated for congressional leaders to enact network adequacy requirements into federal law.

Congress is debating legislation to address unanticipated medical bills due to insurance health plans with inadequate networks of physicians, hospitals, and other providers. As part of that discussion, the CAP responded on February 18 to questions posed by a bipartisan, bicameral group of lawmakers led by Sen. Bill Cassidy, MD (R-LA).

In the response, the CAP advocated for federal enactment of network adequacy requirements similar to one in Sen. Cassidy’s home state of Louisiana. The state’s law requires insurance plans to maintain networks of providers that includes hospital-based physicians such as pathologists. California and New Hampshire are two other states with specific hospital-based physician network adequacy requirements. But with most states lacking statute to protect patients, federal law should compel insurance plans to maintain adequate networks of hospital-based physicians.

The CAP also pointed to data showing health plans refusal to contract with physicians at in-network facilities, including pathologists at independent clinical laboratories. In Texas, the Center for Public Policy Priorities reported one health plan had no pathologists at 20% of its in-network hospitals in 2014. More recently, the Texas Department of Insurance fined a health plan $700,000 for failing to contract with hospital-based physicians in major metropolitan areas.

The CAP also noted that health insurance plans have fought to deny physicians from waiving out-of-network charges for patients, including when a patient cannot afford to pay a bill. For example, a health plan in Louisiana stated providers cannot waive a beneficiary’s cost sharing obligations and any amounts the provider waives may be a “fraudulent claim because it includes amounts that the member is not being charged and will be reduced by the total amount waived.”

Hospitals Ask Congress to Also Protect Patients

Responding to the same inquiry, six organizations representing hospitals and medical centers urged congressional leaders to ensure patients have access to comprehensive provider networks and accurate network information.

“Health plans should provide easily-understandable information about their provider network, including accurate listings for hospital-based physicians, so that patients can make informed health care decisions,” the hospital organizations said. “Patients should have access to a comprehensive network of providers, including in-network physicians and specialists at in-network facilities.”

The letter was signed by the American Hospital Association, America’s Essential Hospitals, Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association, and Federation of American Hospitals.

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The CAP and the Connecticut Society of Pathologists (CSP) urged state lawmakers to oppose legislation that would expand the definition of a “surprise bill” to include bills for nonemergency health care services rendered by out-of-network (OON) clinical laboratories.

In a February 7 statement submitted to the state legislature, the CSP President William Frederick, PhD, MD, FCAP, said that there are many highly valid medical reasons that referrals are made to out-of-network laboratories outside of the facility setting. “If the medical reasons for such testing are explained to the patient by the ordering physician and the patient consents in writing to such testing, the situation is not a ‘surprise’ and should not be subject to this law,” he said.

Currently, health plan payers have complete control of rate-setting for the hospital-based specialties of anesthesiology, pathology, and radiology, which allows them to pay in-network rates for those services. The only exception is for emergency medicine services, which are mandated to be paid at the 80th percentile of FAIR HEALTH INC. charges. Dr. Frederick argued that the current method of rate-setting for out-of-network emergency services is market based and is a fair practice for both physicians and consumers. As such, he urged that the current law not be amended to expand the definition of a “surprise bill” to include bills for non-emergent health care services rendered by OON labs.

The CAP has long maintained that surprise bills are typically the result of a failure in health plan network adequacy at hospitals and facilities where patients cannot access providers within their health plan network. The CAP consistently advocates for all states to have adequate networks of hospital-based physicians, including pathologists, so that patients do not have to resort to OON services.

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The American Medical Association (AMA) held its 2019 National Advocacy Conference to lobby for policies affecting the practice of medicine during the week of February 11. The AMA’s advocacy included advancing principles to address unanticipated medical bills, prescription drug costs, and combating the opioid crisis.

‘Surprise’ Out-of-Network Billing

The CAP is aligned with AMA policy on providing relief to patients from unanticipated health care costs that insurers won’t cover. The CAP signed onto a letter led by the AMA on this issue. Physician specialty associations and state medical societies point to the prevalence of narrow, and often inadequate, networks of physicians contracted in health insurer plans that lead to unanticipated medical bills. Specific principles physicians asked members of Congress to support were:

  • Insurer Accountability – Provide strong oversight and enforcement of network adequacy.
  • Patient Responsibility – Ensure patients are only responsible for in-network cost sharing rates when receiving an out-of-network bill.
  • Transparency – Give patients who choose in advance to obtain scheduled care from out-of-network care information about their anticipated out-of-pocket costs.
  • Universality – Address unanticipated out-of-network bills in ERISA plans.
  • Setting Benchmark Payments – Avoid caps on payment for physicians treating out-of-network patients.
  • Alternate Dispute Resolutions – Provide for mediation or sequential alternative dispute resolution process for those circumstances where the minimum payment standard is insufficient.
  • Keep Patients Out of the Middle – Eliminate burdens on patients when payment rate negotiations should be between insurers and providers.

The CAP is a part of the AMA House of Delegates and encourages members to renew their AMA membership and work together to help shape a health care system that best utilizes pathologists to deliver high-quality care and meets the evolving demands of patient care. The CAP and AMA work together on many health and medical policies that affect the way you practice and your reimbursements. Join or renew your AMA membership today.

Go to the AMA’s website for more information about the 2019 National Advocacy Conference.

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Recently, the CMS discovered an error in the implementation of the 2019 Merit-based Incentive Payment System (MIPS) payment adjustments applied by Medicare Administrative Contractors. The error stems from a recent change to Medicare statute, but the CMS could not make the needed changes in time.

Once the CMS makes the correction, the Medicare agency will adjust the affected claims shortly in two ways:

  • If the CMS overpaid a claim based on this error, you would get a notification for recoupment from your Medicare Administrative Contractor.
  • If the CMS underpaid a claim, the payment for the claims would be adjusted accordingly.

The CAP will continue to report any future changes on MIPS payments or adjustments.

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