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A US District Court judge dismissed a lawsuit led by the American Clinical Laboratory Association (ACLA) that sought to correct the Department of Health and Human Services’ (HHS) implementation of a 2014 Medicare law that established private market rates for services paid through the clinical laboratory fee schedule (CLFS). The CAP supported the lawsuit and filed an amicus brief in February.

CAP President R. Bruce Williams, MD, FCAP, expressed disappointment following judge’s decision and encouraged Congress to take action.

“The CAP supported ACLA’s lawsuit to correct how the administration executed market-based reforms to Medicare’s clinical laboratory payment system, which now threatens seniors’ access to vital patient services,” Dr. Williams said. “Pathologists remain concerned over this broken payment system and the drastic Medicare cuts hitting clinical laboratories, especially those in health care shortage areas and rural communities, across the United States today and over the next several years.

“With the court’s decision to dismiss this lawsuit, the CAP will continue its call on Congress to amend the Protecting Access to Medicare Act (PAMA) to protect patient access to laboratory services. Legislation is needed to ensure reimbursements are accurate and truly reflect costs for the clinical tests provided to patients.”

In the decision, the District Court acknowledged arguments raised by ACLA and the CAP, but maintained it was powerless to require the HHS to comply with statutory requirements that will now allow agencies to circumvent Congress’ express directions at the expense of patient care, said Julie Khani, ACLA President.

“HHS’ continued assertion that collecting data from less than 1% of laboratories nationwide meets the standards for a market-based system is indefensible,” Ms. Khani said. “By intentionally omitting data from more than 99% of laboratories, HHS is undermining Congress’ goal of protecting beneficiaries and supporting value-based care delivery.”

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The CAP advocated for issues related to prior authorization, site neutrality, the interoperability of electronic health records (EHRs), price transparency and payment for new pathology services in the proposed Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs regulation.

In a September 24 letter, the CAP urged the Centers for Medicaid & Medicare Services (CMS) to consider proposed changes that determine the payment rates for Medicare services paid under the Medicare hospital outpatient prospective payment system (OPPS) and those paid under the Medicare ambulatory surgical center (ASC) payment system for 2019.

Site Neutrality and Prior Authorization

The CAP is concerned about the proposed site neutral payment regulations in the 2019 OPPS rule. The CMS has proposed to expand the site-specific physician fee schedule (PFS) payment rate to apply to clinic visit services reported under HCPCS code G0463 for all excepted off-campus provider-based departments (PBDs). The CAP said in its comments, “[The] CMS should finalize this proposal as it could result in inadequate payment rates for services furnished in off-campus PBDs.” The CAP opposed the CMS’ proposal to limit the expansion of clinical families that would be covered outpatient department services for excepted off-campus PBDs. The CAP urged the CMS to reconsider their proposed regulation on utilization programs, prior authorization protocols, and other volume control methods that dictate or limit health care provider decision-making may impinge on the practice of medicine and could improperly encumber and curtail medically necessary clinical laboratory and pathology services.

RFI on Interoperability of EHRs

In the proposed 2019 OPPS regulation, the CMS again requested information on promoting interoperability and electronic health care information exchange. Pathologists contribute substantially to the electronic health record but are disadvantaged in the Merit-based Incentive Payment System (MIPS) program because laboratory information systems (LISs) are not Certified EHR Technology (CEHRT). In the letter, the CAP stated it is “actively working to finding a pathway for LISs to become certified. This would in the long term allow possible participation in the Promoting Interoperability category (of MIPS) but more importantly, would allow pathologists to earn MIPS bonus points associated with using CEHRT and show their value in Alternative Payment Models (APMs).”

Moreover, the CAP is concerned that some vendors and hospitals are not readily sharing data needed for connecting to registries for reporting and quality improvement purposes. The CAP urged the CMS to address this issue of information blocking.

Price Transparency and Surprise Billing

The CMS also requested information on improving patient access to provider and supplier charge information, as the agency remains concerned about surprise out-of-network bills and price transparency.

The CAP rejected the suggested prior notification of cost because notification prior to the performance of a health care service requires a potential delay in critical pathology services and could therefore jeopardize patient care.

Specific Payment Issues

The CAP reiterated its support for accurate reporting and payment for services provided during each step of the chimeric antigen receptor (CAR) T-cell therapy process. The CAP urged the CMS to accept earlier recommendations for clarification of the CART product Q code descriptors and for these services to be paid separately. In addition, the CAP advocated for improved policies to promote more accurate payment for stem cell transplants and requested a greater payment for blood product P9073 Platelets, pheresis, pathogen-reduced, each unit through an existing cross-walk.

The CMS will release the final 2019 regulation in November.

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Check out the latest webinar recording

As part of our ongoing commitment to ensure pathologists can successfully participate in new and evolving payment models, the CAP offers MIPS educational webinars.

The third webinar recording, Pathologist Improvement Activities Under MIPS , is available now to download. If you missed it, Diana Cardona, MD, FCAP, reviewed the improvement activities most relevant to pathologists.

The next webinar in the series is open for registration is the 2019 Final Medicare Policy and Payment Changes on November 9, 2018 at 11 AM ET. As one of the most watched webinars the CAP offers, learn as CAP experts review the final regulations to the 2019 Medicare Physician Fee Schedule and the Quality Payment Program.

Presenters are:

Donald Karcher, MD, FCAP

Donald S. Karcher, MD, FCAP
Chair of the Council on Government and Professional Affairs

Emily E. Volk, MD, FCAP

Emily E. Volk, MD, FCAP
Vice-Chair of the Council on Government and Professional Affairs
Chair of the CAP Clinical Data Registry Ad-Hoc Committee

W. Stephen Black-Schaffer MD, FCAP

W. Stephen Black-Schaffer MD, FCAP
Chair of the CAP Economic Affairs Committee

Register today.

Other upcoming webinars in the MIPS series are open for registration:

Quality Measures that Will Improve Your MIPS Score
Tuesday, December 4, 2018, Noon ET
Diana Cardona, MD, FCAP
Examine ways of improving your performance and MIPS scores using CAP-developed quality measures.

Steps to Take Before Reporting MIPS Data
Tuesday, January 8, 2019, 3PM ET
Emily Volk, MD, MBA, FCAP
Discover ways of maximizing your scoring for 2018 before submitting results to CMS.

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Are you being paid fairly for the services you provide? Payment for pathology services has a direct impact on the success of your practice. Do you know who makes these decisions—and what criteria they use? Are there steps you can take to ensure fair compensation? These topics and more will be explored at CAP18.

Educational Sessions

  • MACRAscopic Analysis of the New Quality Payment Program: Maximize Reimbursement While Demonstrating Value (S1620)
  • How Is My Payment Determined for Pathology Services? Non-CME course (STA008)
  • The CAP’s Policy and Advocacy Agenda (STA010)
  • The Role of Pathologists in Population Health: An Interactive Discussion (STA011)
  • What You Need to Know About the CAP’s Pathologists Quality Registry Non-CME course
  • Lunch Roundtables
    • Current Payment Policy Challenges in Pathology Practice (R1691)
    • My Surgical Pathology and Cytopathology Coding Dilemmas: Getting It Right—An Advanced Discussion (R1690)

Learning Pavilion Sessions

  • Understanding and Maximizing your MIPS Score
  • How to Keep Your Practice Afloat While Reimbursement Rates Decline

CAP Exhibit Booth

  • Pathologists Quality Registry Demos
  • MIPS Resources for Pathologists
  • Billing and Cost Assessment Toolkits

Registration is now open for vital CAP policy and advocacy courses and roundtable discussions during CAP18.

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