STATLINE

Read the Latest Issue of STATLINE

In This Issue:

• Medicare Finalizes Increases to Pathology in 2016 Fee Schedule; Register for Thursday's Webinar
• CAP, AMA Call for NAIC to Ensure Network Adequacy in Covered Health Care Services
• Medicare Physician Compare Website Review Deadline Is November 16

During a November 5 webinar, the CAP will explain reimbursement and policy changes to pathology services in the 2016 Medicare Physician Fee Schedule. The Centers for Medicare & Medicaid Services (CMS) finalized increases sought by the CAP for pathology services, including immunohistochemistry and in situ hybridization, in the final 2016 Medicare fee schedule published on October 30.

Learn more about these and other changes by attending the CAP's November 5 webinar "The 2016 Medicare Physician Fee Schedule's Impact on Pathology Services ." The webinar will begin at 2 PM ET. If you are unable to attend the live session, you should still register so you will receive a link to the archived version of the presentation.

Register for the webinar today.

A STATLINE special report to members stated the CMS estimates the initiatives included in the final 2016 fee schedule would result in an overall increase of 8% for pathology services next year. This estimate would impact overall payment to pathologists by a 4% increase based on the changes to the work relative value units used to calculate the professional component of pathology services as well as the global payment. The impact on changes to the practice expense used to calculate the technical component as well as global payment resulted in a 4% increase in pathology payment.

The physician fee schedule payment received by independent laboratories is estimated to increase by 9% in 2016: 1% increase is attributed to changes in the physician work values and 7% is attributed to changes in the practice expense values (the CMS notes the total may not be equal to the sum of changes to physician work and practice expense values due to rounding). The impact upon an individual pathologist or practice would depend on the mix of services provided.

The CMS states that several specialties, including pathology and independent laboratories, will experience significant increases in payment resulting from the Misvalued Code Initiative, including the establishment of relative value units (RVUs) for new and revised codes. For 2015, the CMS had discounted the add-on services for immunohistochemistry and in situ hybridization services from the original RUC recommended work RVUs by 40%, based on flawed assumptions. For 2016, the CMS increased the physician work values for the add-on codes, but included a 24% discount in the add-on services compared to the base code.

While this change represents increased values, the CAP maintains that no discount should be taken from recommended values for the add-on services.

Download the CAP's impact table analysis of the 2016 fee schedule.

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The CAP, American Medical Association (AMA), and other physician and patient advocacy groups have urged the National Association of Insurance Commissioners (NAIC) to ensure access to covered health care services in model legislation that attempts to address insurance network adequacy standards.

In an October 26 letter, the CAP joined numerous national and state organizations to call for revisions to the NAIC's draft Managed Care Plan Network Adequacy Model Act. The letter urged a committee tasked with reviewing changes to the model legislation to focus on active approval of networks prior to products going to market, the use of quantitative measures to determine network adequacy, and regulation of tiered networks to prevent discriminatory network design. Revisions to the Model legislation were under development for almost two years in a stakeholder process which included the AMA, CAP and other hospital based physician organizations. Many of the recommendations made to the NAIC from the CAP and other physician groups were rejected by the regulators, including a specific requirement for health plan network adequacy for hospital based physicians.

With NAIC final approval of the model bill pending, the organizations signing the letter are very concerned, for example, that tiered networks, or networks that assign different levels of consumer cost-sharing to different tiers of providers, are being designed in a discriminatory fashion and hindering access to covered services. For instance, providers that may subspecialize and care for patients with more complex needs may be placed into higher cost-sharing tiers. This forces patients who need to access these providers to pay significantly more out-of-pocket even though such care is a covered benefit. In addition, the lowest cost-sharing tier may not include sufficient numbers or types of providers to offer consumers access to affordable covered services.

In an October 21 letter, the AMA also provided separate comments, which addressed access to hospital-based physicians and other concerns, on the draft NAIC Network Adequacy model bill. A section that would affect out-of-network hospital-based physicians including pathologists, precludes balance billing in certain situations to protect consumers from unanticipated out-of-pocket costs, but would have the negative impact of discouraging insurers from contracting with health care professionals. The section would perpetuate the network issues that prompted the revisions to the model bill, the AMA stated.

"We believe that the issue of so-called 'surprise' billing should be addressed through strong quantitative standards that specifically require regulators to evaluate access to participating health care professionals at participating hospitals in each network," the AMA letter said. "A network that does not provide adequate access to in-network care at contracted hospitals should simply not be sold to consumers. The AMA maintains that this lack of alignment in networks is the root cause of surprise billing issues and is inadequately addressed in this model."

The AMA suggested additional edits to lessen the negative impact this proposal might have on state markets and to help clarify the rights and responsibilities of impacted parties. For example, a fair payment standard based on independent, out-of-network charge data.

The CAP will continue to engage on this issue and report more information in future editions of STATLINE. The NAIC is scheduled to consider adoption of proposed revisions to the model legislation on November 3.

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The CMS' Physician Compare website, an initiative allowing patients to search for physicians who provide Medicare services, preview period is now open and will end on November 16. The Physician Compare website will contain information on individual participation in certain Medicare quality initiatives.

Physicians can now preview the quality measures, based on participation in 2014, on the website before they are made public. Physicians can access the secured measures preview site through the Physician Quality Reporting System (PQRS) portal-Provider Quality Information Portal (PQIP). To learn more about which measures will be publicly reported and how to preview your measures, visit the Physician Compare Initiative page.

For questions about Physician Compare, public reporting, or the 2014 quality measure preview period, email PhysicianCompare@Westat.com.

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