Read the Latest Issue of STATLINE

May 2, 2017

In This Issue:

From Left to right Dr. Elizabeth Rinehart, Dr. Lisa Cohen, Dr. Beatriz Tapia-Centrola, Dr. David Gang and Dr. Petronela Iorga.

During the final day of the 2017 CAP Policy Meeting, pathologists met with the offices of their elected officials and urged members of Congress to support legislation to increase transparency and accountability in the Medicare local coverage determination (LCD) process. Because of CAP's presence on the Hill, the CAP is excited to announce that Sens. Chuck Grassley (R-IA) and Pat Roberts (R-KS) have signed on to be co-sponsors of the Local Coverage Determination Clarification Act of 2017. Sens. Grassley and Roberts join Sen. Johnny Isakson (R-GA), Sen. Tom Carper (D-DE), Sen. Debbie Stabenow (D-MI) and Sen. John Boozman (R-AR) as co-sponsors of the bill.

The CAP's Annual Hill Day included 81 pathologists visiting 73 House offices and 54 Senate offices. CAP members also dropped off information packets about LCD process reforms at several other congressional offices.

Many returning and some new meeting Hill day attendees were excited and ready to meet with the Federal legislators. David Gang, MD, FCAP a veteran of the CAP Policy Meeting from Springfield, MA, and Elizabeth Rinehart, MD, BOG member and Chair of the Residents Forum, led meetings with the Massachusetts CAP contingent with health policy staff in Sen.Elizabeth Warren (D-MA) and Sen.Edward Markey (D-MA) offices. Joining Drs. Gang and Reinhart for the first time were Beatriz Tapia-Centrola, MD, FCAP, Lisa Cohen, MD, FCAP, and Petronela Iorga, MD, FCAP.

Since 2012, CAP members have participated in 868 meetings with congressional offices and achieved several victories. For example, physicians successfully advocated for the repeal of the sustainable growth rate (SGR) Medicare payment formula. CAP members also have successfully avoided Medicare payment penalties from the Electronic Health Record (EHR) Meaningful Use program after engaging with members of Congress at previous Policy Meetings and through the CAP's grassroots network PathNET.

At the 2017 Policy Meeting, CAP members cited problems in the current LCD development process and asked for Congress to institute several changes. CAP Members shared the LCD Infograph with congressional staff during their meetings. Those changes are:

  • Require open meetings: Make Medicare Administrative Contractor (MAC) carrier advisory committee meetings open, public, and on the record with published meeting minutes.
  • Establish upfront disclosure: Require a MAC—at the outset of the process—to include a description of the evidence the MAC considered when drafting an LCD and rationale it is relying on to deny coverage.
  • Create meaningful reconsideration and options for appeal: Codify a meaningful LCD reconsideration process that gives providers and suppliers the opportunity to have a qualified disinterested secondary review of a reconsideration denial.
  • Stop the abuse of LCDs as a backdoor to national coverage determinations (NCDs): Prohibit the Centers for Medicare & Medicaid Services from appointing a single MAC that can make local determinations used on a nationwide basis.

The CAP expects the LCD bill to be introduced in the House soon. STATLINE will continue to monitor the situation and will provide any future updates.

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The CAP is fielding the 2017 Practice Characteristics Survey to gather data from individual pathology practices regarding their economics, demographics, and market trends. The survey is open for one more week, until May 12.

On April 10, pathologists received an email from with a link that is unique to the pathologist receiving the invitation. Respondents are eligible for a drawing for one of four $150 Amazon gift cards. This week Melissa H. Fowler, MD, FCAP of Erie, PA won the $150 Amazon gift card for completing the survey.

If you have not received your invitation, please contact us at This survey is available to board-certified pathologists who are currently practicing in the US. The survey excludes full-time retirees, pathologists practicing in different countries, and junior members of the CAP.

The survey should take 15 minutes to complete. The CAP will share the survey findings with its members in a full report and provide early access to the data to those who finish the survey.

All responses are kept strictly confidential. Responses will be reported in aggregate form only. No individual practice information will be uniquely identified or shared.

The CAP will use the data in its advocacy efforts with policy influencers, health care leaders, and other stakeholders to increase understanding of the significant role and value of the pathologist in the delivery of patient care.

Survey participants are helping the CAP to better serve its members. The survey will capture:

  • Vital practice member characteristic data
  • Information on the concerns and challenges of the CAP member
  • Compensation data, including salary and benefits
  • Practice-related data

Complete your survey soon before it closes on May 12.

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Arizona Gov. Doug Ducey signed into law a bill that allows health plan enrollees who receive an unanticipated medical bill from an out-of-network (OON) provider to dispute the bill through claims arbitration. The measure bans balance billing of patients for bills over $1,000 that are subject to arbitration, but only after the patient agrees to make payment to the provider for applicable co-payments, deductibles, and co-insurance. The new law takes effect Jan. 1, 2019.

The House on April 19 approved S.B. 1441, as amended, by a vote of 40-19. The measure was approved by the Senate. The bill was the largely the result of a legislative compromise engineered by the Arizona State Medical Society. Both CAP and the Arizona Society of Pathologists believe that the Arizona State Medical Society averted a potentially adverse outcome and commends the state medical society for the legislative success. The Arizona State Medical Society used the Texas out-of-network law, which also provides for mediation, as its initial point of negotiation. The CAP engaged with the Arizona State Medical Society on this issue.

Right to Arbitration

Under the bill, consumers can ask the Arizona Department of Insurance to assign an arbitrator to settle the dispute if they receive a bill of $1,000 of more from OON providers. However, patients, insurers, and providers must first try to settle the dispute through a settlement teleconference before proceeding to arbitration.

The measure requires the department to develop a simple, fair, efficient and cost-effective arbitration procedure for bill disputes and specifies time frames, standards and other details of arbitration. It also establishes criteria for qualifying as an arbitrator and specifies how the proceedings should be handled. For example, arbitration must be conducted within 120 days after a request is received, a final decision must be rendered within 10 business days, and the cost of arbitration must be split between the insurer and provider.

Network Adequacy at Heart of Problem

A number of states have enacted laws specifically limiting balance billing by OON providers under certain circumstances. Others, such as Oregon, are attempting to link OON physician payment to Medicare, as California currently requires.

The CAP has long advocated for measures that address the problem of network adequacy rather than those that simply target OON billing. OON billing, also known as "surprise billing," is on the increase primarily because insurance companies continue to narrow their networks of providers. CAP’s position on OON billing is that if the health plan does not provide the patient with an in-network provider option, the patient should pay the in-network rate and the health plan should be responsible for the balance billed amount. The CAP also believes that any state-approved health insurance plan network should be subject to plan adequacy requirements that include adequacy of in-network pathologist participation.

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An Oregon bill that would link the state's out-of-network (OON) physician payment formula to Medicare could result in cuts to hospital payments of up to 10 percent, argue the Oregon Pathologist Association (OPA) and the CAP in a letter opposing the measure.

House Bill 2339A, designed to prohibit health care providers or participating health care facilities from balance billing patients for services provided at a participating facility, would link OON payment to 175 percent of Medicare for non-emergency services. The measure passed the Oregon House on April 11 by a vote of 36-22. It is now pending before the state Senate.

While the OPA and the CAP support efforts to keep patients out of the middle of reimbursement issues, they argue that the Medicare formula used in the bill would improperly limit what a health plan can pay to an OON physician, including pathologists, thereby devaluing certain physician services.

The OPA and the CAP support payment to OON physicians in accordance with usual and customary rates that reflect the market value of physician services based upon an independent database of charges that are determined by geography say the organizations in an April 25 letter to Sen. Laurie Monnes-Anderson, chair of the Oregon Senate Health Care Committee. Other states – including Florida, Minnesota and New York – have adopted such as the market-based formula for payment.

"A recent report from the RAND Corporation concluded that for the State of New Jersey, an analog payment rate for out-of-network payments set between 90 percent and 200 percent of Medicare could reduce payments to hospitals by between 6 and 10 percent," writes OPA President Mohiedean Ghofrani, MD, MBA, FCAP. "We would expect a similar adverse impact on Oregon hospitals that cannot afford such cuts, especially in light of the uncertainty regarding the Affordable Care Act and the future of Medicare payment. Quite simply, use of the Medicare fee schedule to control the private insurance market tips economic leverage in favor of the insurance industry to the detriment of providers and the health care delivery system."

Further, because the Medicare fee schedule was designed only for medical services rendered to a person over the age of 65, some medical services – including some pathology and some genetic screening services – are not covered by Medicare. What’s more, the fee schedule is created in the context of a government program, not to service the private insurance market.

"For these many reasons, using a Medicare mechanism will remove economic or regulatory incentives for health insurance plans to contract with hospital-based physician specialists for their services," writes Dr. Mohiedean in expressing his opposition to the bill.

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Matthew Foster, MD, FCAP

STATLINE regularly features one of the many the CAP members who have been champions for pathology in Washington and at the state level through our grassroots and PAC programs. If you would like to get involved, you can join PathNET, contribute to PathPAC, or join your state pathology society.

Name: Matthew Foster, MD, FCAP
Position: Pathologist, Pathology Consultants of Central Virginia; Associate Medical Director, Alan B. Pearson Regional Cancer Center

What is one issue hindering your career/practice that advocacy can help with?

While there are many challenges and a great deal of uncertainty surrounding health care in general, the commoditization of physicians, and pathologists specifically, seems overshadowed by discussions of regulatory oversight, finance, and quality metrics. Pathologists may be overlooked in discussions of alternative payment models, health insurance networks, or even medical staff leadership for instance. They instead may be regarded as interchangeable parts available to the lowest bidder; as personnel who are easily replaced, like a small part in the inner workings of a large and unwieldy machine.

Often, when I tell someone what I do for a living, I am met with a blank stare or an "oh…hmmm, providing a clear acknowledgment that they have only a vague concept of what a pathologist does. The CAP continues to do a tremendous job of promoting the specialty of pathology but we, the pathologists, should be the loudest voices for our profession.

What advice would you give to someone who wants to be involved in advocacy?

Pathologists have a tremendous amount of quiet influence just in their daily work. Don't be afraid to speak up. Use the skills and talents of communication you have developed as a pathologist to advocate for your specialty. Use your voice. We are trained to effectively communicate to clinicians and patients, and also to educate. Those same talents can translate into effective advocacy. We would do well to remember our credibility as physicians in the eyes of political leaders and use that to our advantage by harnessing our skills as communicators.

We are witnessing a dramatic paradigm shift in health care in our country, and I used to wonder if my voice, as a pathologist in a small community, would matter. That it would not make any difference whether I got involved or not because my perspective would be lost in the cacophony of other louder, visible, and more familiar voices. It is easy to be cynical. Change is not always visible. The ways advocacy has shaped the profession of pathology are similar to the ways in which the practice of pathology impacts clinical patient care. It may not seem apparent at first, but we have a voice and it is effective.

Do you have a favorite memory or experience that stands out in your advocacy work?

Having the opportunity to have breakfast with Sen. Mark Warner remains a highlight. There were ten of us together standing around a square table in a small hotel conference room. He walked in and I sat right next to him, and for the next hour we shared a meal and had a roundtable discussion. Not only was I the only pathologist in the room, I was the only physician. Health care was a common theme during that discussion, and I was able to speak directly to Senator Warner at length about issues facing the house of medicine and specifically pathology.

Legislators at the local, state, and national level, like other members of the general public, may have only rudimentary knowledge of the value and importance of pathology. It is up to us to be the face and voice of our specialty.

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