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In This Issue:

Donald Karcher, MD, FCAP

The CAP was one of the provider groups at the Centers for Medicare and Medicaid Services (CMS) Patients Over Paperwork Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience.

The CAP, represented by Donald Karcher, MD, FCAP, Chair of the Council on Government and Professional Affairs, was among 35 other provider associations and organizations, including the American Hospital Association and the American Academy of Family Physicians, to discuss reducing regulatory burdens in health care. During the session, Dr. Karcher spoke with the CMS Administrator Seema Verma on PAMA, including delaying the implementation of PAMA to resolve significant substantive and operational issues, reassessing and redefining the current regulatory definition of "applicable laboratory, and allowing more time for laboratories to be able to fulfill the CMS data collection requirements."

Through the launch of the Patients Over Paperwork Initiative, the CMS, along with its partners and stakeholders, emphasized its commitment to removing regulatory obstacles that get in the way of providers spending time with patients.

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Not sure if you're in an Accountable Care Organization or other advanced alternative payment model for purposes of QPP reporting? The CMS has a tool for providers to check their eligibility with the Qualifying APM Participant (QP) Look-up Tool.

However, the CAP discovered a data issue when looking up status as an Advance Alternative Payment Model (APM) participant which is causing confusion among physicians. If you are in an Advance APM as indicated by the CMS' Qualifying APM Participant Look-Up Tool, you do not have to participate in the 2017 MIPS program. The MIPS program is not able to cross reference if you are a part of an Advance APM on the QPP website. If you have a QP Status on the QP Lookup Tool, this status overrides the eligibility for the MIPS program.

Once you know if you are eligible for MIPS, the CAP has a free 2017 MIPS Reporting Solution.

The CAP and its registry vendor partner FIGmd are offering pathologists free access to registry reporting to aim for a full bonus in Medicare’s Merit-based Incentive Payment System (MIPS).

Pathologists can use the 2017 MIPS Reporting Solution to maximize their opportunity to increase their Medicare payment. There is no cost to report with the 2017 MIPS Reporting Solution. Learn more about enrolling and using the 2017 MIPS Reporting Solution.

With the 2017 MIPS Reporting Solution, pathologists can fully meet program requirements.

  • If you currently report quality measures through billing or other ways: Increase your bonus potential by attesting for the improvement activities.
  • If you have not decided how to report for MIPS 2017: Report on quality measures for a 90-day period—or a full year of patients—and attest to improvement activities to increase your payment potential and, at a minimum, avoid a payment penalty.

The 2017 MIPS Reporting Solution includes eight pathology-specific quality measures developed by the CAP and all 92 improvement activities included in the MIPS program. The CAP has identified a subset of the improvement activities that are most pertinent to pathologists (e.g. reports to referring physicians, maintenance of certification part IV, etc.)

Contact CAP registry staff if you have questions about the 2017 reporting option.

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The CAP advocated on the CMS CLIA–Fecal Occult Blood (FOB) testing proposed rule to clarify that the waived test categorization applies only to non-automated fecal occult blood and remove the hemoglobin by copper sulfate method from the list of waived tests. In a comment letter, the CAP is the leading laboratory accrediting group and would like the CMS to ensure that any new technology must undergo undergoes adequate review before receiving CLIA waiver status; but also have the belief that waived testing poses risk to patients in certain settings.

Under CLIA, regulatory oversight is waived for tests that are cleared by the Food and Drug Administration (FDA) for home use; employ methodologies that are as simple and accurate as to render the likelihood of erroneous results negligible, or pose no reasonable risk of harm to the patient if the test is performed incorrectly. Advances in medical technology and instrumentation have enabled physicians to do more and more sophisticated testing which is leading to more rapid and appropriate diagnosis and therapy. Therefore, the CAP believes it is appropriate to require "automated FOB tests" to be evaluated through the FDA CLIA waiver process instead of automatically waiving these devices as the original CLIA regulations necessitate.

The CAP thinks that waived testing poses risk to patients in certain settings and would like any proposed technology to undergo a review before receiving CLIA waiver status.

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A clash between the Tennessee Society of Pathologists (TSP) and Blue Cross Blue Shield of Tennessee (BCBST) over payment denial for the technical component (TC) of Anatomic Pathology Services provided has prompted the intervention of the Tennessee Department of Commerce and Industry and a partial concession by BCBST.

As BCBST included ambulatory surgical centers under the purview of their TC payment denial activities, the CAP urged the TSP to invoke the legal protections of the anatomic pathology direct billing law in their discussions. Following consultation with the CAP, the TSP retained legal counsel on the matter and secured state interest in the issue. The recent BCBST communication, while appearing to concede on TC payment for services at ambulatory surgical centers, left many aspects of the issue unresolved.

In their October 27 response to the Department, BCBST states, "Due to the confusion surrounding this payment methodology as it relates to technical component services provided in an ambulatory surgical center, BCBST will allow pathologists and independent laboratories to bill under the physician fee schedule.

For several years, BCBST has maintained that payment for the TC is made to the facility and not directly to pathologists, and has cited Medicare as its model. In their communication to BCBST, the TSP legal counsel argued both statutory and contractual obligations compel BCBST to make payments for the TC of anatomic pathology directly to pathologists. Arguing that the BCBST payment scheme implicated several state laws, the TSP successfully urged the intervention of the Tennessee Department of Commerce and Industry.

In its response to the state, BCBST goes on to state that: "This change will be effective on a retroactive basis, to August 25, 2017. Anatomic pathology technical component claims with dates of service on and after August 25, 2017, can be paid under the physician fee schedule; claims with dates of service on and after August 25, 2017, that was previously adjudicated and denied based on BCBST's policy will be re-processed and payment will be made. The BCBST will cease recoupment efforts related to billing/payment for anatomic pathology technical component claims for patients in an ambulatory surgical center for claims with dates of service prior to August 25, 2017."

BCBST did not openly acknowledge the direct billing law’s prohibitions as stated in their its letter.

Joe Saad, MD, FCAP, Chair of the Federal and State Affairs Committee noted that: "The relevance of the direct billing law to this matter highlights a new value in these laws that the CAP secured in 19 states. Had it not been for the CAP's and TSP's advocacy efforts going back a decade this particular statute could not have been invoked as a defense against adverse actions by a health insurance payer." The TSP will continue to pursue addition clarification from BCBST on TC payment for both the hospitals and ambulatory surgical centers until the matter is resolved.

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Thursday, November 9, 2017
12:00 PM CT

In the next few weeks, the Centers for Medicare & Medicaid Services' (CMS) will finalize the 2018 Medicare Physician Fee Schedule with changes to reimbursement rates for pathology services next year. On Thursday, November 9 at 1 pm ET/12 pm CT find out which pathology payment changes will affect your practice during this informative webinar.

The CAP engages with the CMS directly to protect the value of pathology services for its members and through its direct work with the AMA Specialty Society Relative Value Scale Update Committee (RUC) for physician work relative values. Led by Donald Karcher, MD, FCAP, Chair of the Council on Government and Public Affairs, W. Stephen Black-Schaffer, MD, FCAP, Chair of the Economic Affairs Committee, and Jonathan Myles, MD, FCAP, of the Board of Governors, this 60-minute webinar will review how the final fee schedule will affect services, such as therapeutic apheresis, pathology consultations during surgery, and tumor immunohistochemistry in 2018.

Register today.

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Wednesday, November 29, 2017
12:00 PM CT

In the coming weeks, the Centers for Medicare & Medicaid Services (CMS) will issue its final update to the 2018 Quality Payment Program and its Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) program.

In 2018, most pathologists will need to take action to stop penalties from reducing future Medicare payments for their services and nearly all pathologists will be required to participate in MIPS.

On November 29, the CAP will host a 60-minute webinar to discuss 2018 options for preventing Medicare penalties and, in certain cases, increase reimbursements in 2020. The webinar will begin at 1 PM ET and will be moderated by Donald Karcher, MD, FCAP, Chair of the CAP Council of Government and Professional Affairs. Dr. Karcher will be joined by W. Stephen Black-Schaffer MD, FCAP, Chair, of the CAP Economic Affairs Committee and; Diana Cardona, MD, FCAP, Chair of the CAP Economic Affairs Measures & Performance Assessment Subcommittee, who will discuss how these proposed Medicare program changes under the Quality Payment Program will affect pathologists in 2018.

Register today.

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Registration is open for now the 2018 CAP Policy Meeting–Protecting the Practice of Pathology and Our Patients.

The annual CAP policy meeting, which is set for from April 30–May 2 at the Washington Marriott in Washington, DC, enables CAP members to connect with government leaders and policy experts to discuss the impact of federal regulation on their pathology practices.

New regulations are taking shape that will impact pathology reimbursements for years to come. Attendees at the CAP Policy Meeting will receive the latest information and analysis on the implementation of new Medicare and laboratory regulations. The CAP is actively engaged in the legislative and regulatory arenas on the critical issues facing pathology and laboratory medicine, including physician payment reform, reducing regulatory burdens, and improving health care quality.

The CAP Policy Meeting will also include meetings with members of Congress and their staff during the CAP’s Annual Hill Day on May 2, which is the specialty's opportunity to focus on the federal issues most important to pathologists now and in the future.

The CAP Policy Meeting is a benefit of CAP Membership. There is no fee to register.

Register for the 2018 Policy Meeting.

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