Advocacy Update

Read the Latest Issue of Advocacy Update

May 21, 2019

In This Issue:

The CAP commended the enactment of a Washington state law to protect patients from surprise out-of-network medical bills by banning balance billing for certain out-of-network services and requiring health insurance plans to maintain adequate networks of physicians at in-network hospitals and facilities.

Washington Gov. Jay Inslee signed the bill into law on May 21. State law requires regulators to determine whether the insurance carrier’s provider network has a sufficient number of contracted physicians, including emergency, surgical, and other specialty physicians such as pathologists. The patient protections enacted by the state apply to health plans regulated by the Washington Commissioner of Insurance.

“Health plans with inadequate networks are the root cause of surprise bills,” said CAP President R. Bruce Williams, MD, FCAP. “For years, insurance companies have narrowed networks and we have seen the impact on our patients receiving surprise medical bills. By setting network adequacy standards, the state of Washington will ensure access to lifesaving medical care and reduce instances of out-of-network bills. We encourage Congress to pass similar legislation to ensure patient access and take necessary steps toward protecting all Americans from surprise bills.”

Physicians, patients, and other health professionals support ensuring health insurance plans maintain adequate provider networks. In a public national declaration on health plan network adequacy, pathologists, radiologists, and hospitalists, in addition to 11 patient advocacy groups all urged state and federal lawmakers to require health plans be subject to the requirement.

After Louisiana and New Hampshire, Washington is now the third state requiring health plan network adequacy for hospital-based physician specialists. Other key highlights of the new Washington law include: 

  • A statutory reimbursement rate or mechanism for out-of-network reimbursement requiring payment to be set at a commercially reasonable rate.
  • A dispute resolution process.
  • Direct payment from carriers to physicians, which prohibits carriers from routing payment through patients.
  • Requirements pertaining to transparency and enforcement of the law.

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The CAP, American Medical Association, and other physician organizations led a briefing for congressional staff on May 16 to discuss a legislative approach to protect patients against surprise medical bills.

At the forum, the CAP’s advocacy was well represented and was echoed by associations representing other physician specialties. The CAP seeks a solution that addresses the impact of unanticipated medical bills on patient out-of-pocket costs. The benefits of law in New York state was discussed as one example that takes patients out of the middle of surprise billing disputes. Physicians also emphasized that they prefer to be in-network, but, because of the narrowing of provider networks and health plan market dominance, physicians are often left out-of-network to the detriment of patients.

In addition to the CAP, hosts for the May 16 briefing were: American College of Radiology, American Association of Neurological Surgeons, American College of Emergency Physicians, American College of Surgeons, American Medical Association, American Society of Anesthesiologists, and the Congress of Neurological Surgeons.

In recent weeks, federal lawmakers from the House and Senate have unveiled several legislative proposals to eliminate surprise medical bills. The CAP has engaged and will continue to engage with congressional offices to address concerns of pathologists and their patients.

During the CAP’s 2019 Policy Meeting, pathologists advocated to hold patients harmless, set network adequacy standards for hospital-based physicians, and establish a fair reimbursement system for care provided out-of-network at in-network hospitals. Pathologists can also continue to urge their representatives and senators to pass reforms supported by the CAP by using the advocacy action center.

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The CAP has engaged with Anthem Blue Cross and Blue Shield (BCBS) to understand the insurer’s rationale for proposing reductions to reimbursement for pathology services.

In recent months, Anthem BCBS began sending letters and other communications regarding cuts to pathology services on its fee schedule. The reimbursement policy affects, or will soon affect, Anthem’s commercial and Medicare Advantage insurance products in states such as Alaska, California, Indiana, Missouri, and Ohio. An example of a notification to physicians in Indiana is published online.

For pathologists practicing in one of these areas who are not aware of formal communication from Anthem, the CAP encourages you to contact your regional network manager to find out whether the reductions apply in your region.

During the CAP’s discussion with Anthem BCBS, representatives for the insurer said the reason for the change is disparity across parts of their network and a need to rebalance rates regardless of setting. The CAP understands there could be several factors contributing to the change and is pursuing follow-up with Anthem to get additional clarity and determine any next steps.

Anthem BCBS further asked physicians with questions about fee schedule changes to contact their regional network manager for additional information.

The CAP will continue to engage with Anthem going forward.

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The Centers for Medicare & Medicaid Services delayed the agency’s final coverage decision on how chimeric antigen receptor T-cell (CAR T-cell) therapies will be covered under Medicare. The decision was supposed to come out on May 17. The decision to delay the final coverage decision is in direct response to stakeholders. In its comments on the proposed National Coverage Determination the CAP requested that the new procedures involving CAR T-cell therapies needed increased reimbursements and a more flexible process. 

The agency published a statement on May 17 that the “CMS will not be issuing a final National Coverage Determination on CAR T-cell therapy for cancer today, but a decision is forthcoming.”

CAR-T cell therapy is the first-ever gene therapy used to treat certain forms of cancer for which no other treatment options exist. The CAP has urged the CMS to include a flexible process that allows for evolving cancer therapy technologies for cancer patients and to ensure recognition of the life-saving role that pathologists play in the CAR T-cell treatment process.

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The CAP, along with American Association for Clinical Chemistry (AACC) and 17 other industry stakeholders, worked together to push a House funding bill that would advance laboratory result harmonization or uniform laboratory tests.

The recent House Appropriations Committee passed a $4 million dollar funding bill for the Centers for Disease Control and Prevention (CDC) to broaden its harmonization initiative, which is vital to ensuring that patients receive accurate diagnoses and effective medical treatment.

Patients’ laboratory results can be different depending on where their tests were performed and what diagnostic methods were used. Harmonizing test results is crucial to ensuring that patient laboratory results can be compared and used to accurately monitor changes in health even if, for instance, the patient switches providers or the provider’s laboratory changes instruments.

The CAP, along with the AACC and others, highlighted the importance of laboratory test harmonization and secured this funding.

With this funding, the CDC would have the resources to provide materials and monitor laboratories and manufacturers nationwide to improve the accuracy and precision of their test measurements. Moreover, these efforts would improve diagnosis, treatment, and preventative measures for diseases.

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The CAP launched a new monthly Advocacy News Quiz where you can test your knowledge and share your scores on social media. CAP members can take this quiz, share their results, and encourage others to participate. Good luck!

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This is the final stretch of the 2019 Practice Characteristics Survey. Pathologists can shape the CAP’s advocacy priorities by providing pathology practice data regarding recent economic, demographic, and market trends. The survey is open through May 22.

Respondents who complete the survey by May 22 are still eligible for the grand prize drawing for an Apple Watch® Series 4 wrist-wearable device. This week’s winner is Jose E. Olivella, MD, FCAP, from Boynton Beach, FL, who is the winner of a $150 Amazon gift card.

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 not take more than 15 minutes to complete. The CAP will share the survey findings in a full report and provide early access to the data to those who finish the survey. If you have not received your invitation, you can take the survey.

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Advocacy Update will take a scheduled break on May 28 due to the Memorial Day holiday. You will receive the next edition of Advocacy Update in your email inbox on June 4. Please continue to check the CAP TWITTER, FACEBOOK, and CAPCONNECT accounts for updates from the CAP.

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