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July 11, 2017

In This Issue:

The CAP is strongly focused on securing more cosponsors for the Local Coverage Determination Clarification Act (S. 794), legislation to fix the flawed LCD process introduced by Senators Johnny Isakson (R-GA), Thomas Carper (D-DE), John Boozman (R-AR), and Debbie Stabenow (D-MI). Since the introduction of the bill in March, two additional cosponsors have signed on, Sen. Charles Grassley (R-IA) and Sen. Pat Roberts (R-KS). The CAP is also pursuing introduction of the bill in the House.

The bill would improve transparency and accountability when Medicare contractors implement LCD policies for physician services provided to Medicare beneficiaries. In the current legislation, the CAP calls for coverage decisions to be made by qualified health experts through a transparent process based on sound medical evidence.

Most recently, the CAP added 26 state and regional rheumatology societies to its coalition, bringing the total to over 100 medical and patient groups supporting S. 794, including AdvaMed, the Amputee Coalition, the American Medical Association (AMA), the American Society of Clinical Oncology (ASCO), and the American Society for Radiation Oncology (ASTRO). These organizations have come together because they believe that LCDs should not limit patient access to needed services.

The CAP needs your support as it is critical to our success. Members of Congress do listen to their constituents, and they need to hear from you about why this bill is important. You can visit the CAP Action Center to email your senators today, or meet with your legislators in person during the August recess. Surveys of congressional staff indicate that in-person meetings are the best way to influence legislators on the issues. Members of Congress will be back in their home states for the month of August, so now is the perfect time to make the request.

Visit for resources on meeting with your legislators and hosting a lab tour.

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Effective July 1, 2017, California out-of-network (OON) health care providers who render certain services at in-network facilities may be limited to billing patients for the in-network cost-sharing amount. Under AB 72, signed into law last year, non-contracting health professionals are prohibited from billing or collecting any amount above the in-network cost-sharing amount from enrollees. Any overpayments must be refunded. Insurers will pay OON providers the greater of either the payor's average contracted rate or 125% of the then-current Medicare physician fee schedule based on the geographic region where the services were rendered. The CAP has opposed efforts to limit, based upon Medicare or in-network rates, what OON pathologists will be paid for services provided.

However, OON providers may opt out of receiving in-network rates in certain circumstances: 1) the enrollee must have a health plan that includes coverage for OON benefits, and 2) the enrollee must consent to such billing in writing at least 24 hours before receiving care (and the consent must be separate from the document used to obtain consent for any part of the care or procedure).

The OON provider must provide a written estimate of the billed charges prior to getting consent. The provider may not attempt to collect more than the estimated amount without receiving separate written consent, unless circumstances arise during delivery of services that were unforeseeable at the time the consent was given.

The following conditions also apply to the written consent form:

  • The consent must advise enrollees that they may choose to seek care from a contracted provider for lower out-of-pocket costs;
  • The consent and estimate must be provided to enrollees in the language they speak (if the language is a Medi-Cal threshold language);
  • The consent must advise enrollees that any costs incurred as a result of use of the OON benefit shall be in addition to in-network cost-sharing amount and may not count toward the annual out-of-pocket maximum on in-network benefits or a deductible, if any, for in-network benefits.

If all these conditions regarding consent are met, then an OON provider may bill and collect the OON cost-sharing amount from the enrollee. The payor must pay the OON provider the amount provided in the health care service plan contract or insurance policy. This payment will not be subject to the independent dispute resolution process.

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The clock is ticking away and the CAP wants to make sure that your practice is ready to participate in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This new law is changing the way physicians are paid under Medicare.

The CAP developed a MACRA-readiness checklist for pathologists to help pathologists successfully participate in the Quality Payment Program in 2017.

You can use this checklist to improve your performance in Medicare's Quality Payment Program.

You can download it from the Quality Payment Program web page.

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CAP Members from left to right, Patrick E. Godbey, MD, FCAP, Jonathan L. Myles MD, FCAP, and W. Stephen Black-Schaffer, MD, FCAP

On Monday, July 17 at 1:00 PM ET, the CAP will host "Pathology Payment - An Overview of the 2018 Proposed Medicare Physician Fee Schedule Webinar". Throughout this 60-minute panel discussion, CAP experts will review the proposed changes from the Centers for Medicare & Medicaid Services (CMS) 2018 Medicare Physician Fee Schedule. These proposed changes will include Medicare reimbursement and policy changes that will affect pathologists. The final fee schedule will be published by the CMS in the fall of 2017

Learn from Patrick Godbey, MD, FCAP, Chair of the CAP Council on Government and Public Affairs, Jonathan Myles, MD, FCAP, Chair of the CAP Economic Affairs Committee, and W. Stephen Black-Schaffer, MD, FCAP, Vice Chair of CAP Economic Affairs Committee on how the proposed changes to the physician fee schedule will affect pathology services. During the webinar presentation, CAP experts will also discuss the CAP's advocacy efforts to impact these changes.

Register today.

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