CAP: Cigna Should Abandon Plan to Deny Payment for Clinical Pathology Services
The College of American Pathologists (CAP) has urged the insurer Cigna to cancel a nationwide policy that would stop payment for the professional component (PC) of clinical pathology (CP) services beginning March 10.
The College outlined its objections to Cigna’s policy in a five-page, January 10 letter from CAP President Gene N. Herbek, MD, FCAP. Amongst the reasons for opposing Cigna’s policy, the CAP disagreed with Cigna’s position that the updated policy is consistent with CMS practices for billing the PC of CP services. The CAP also underscored recent court decisions that have sided with pathologists in cases involving the PC of CP services.
“The PC of CP services under Cigna’s new policy for which reimbursement will be discontinued are services that are critical to the diagnosis and treatment of patients particularly in a delivery system reliant upon increased coordination, integration, and population management,” the CAP letter stated.
The CAP also is aware that individual state pathology societies and individual local practices are engaged in discussions about the policy with local Cigna representatives.
Cigna asserts it made its decision to deny payment for the services during a routine policy review. As part of a larger claim-processing software implementation, Cigna would no longer pay claims submitted with modifier 26 when billed with laboratory and other codes, although the predominant impact would be on laboratory codes. The policy would be consistent with Centers for Medicare & Medicaid Services (CMS) practices, Cigna has stated.
The CAP spoke with Cigna leadership on the day the College became aware of the change in December. The CAP disputed Cigna’s claim that this change matched CMS’ guidelines and further outlined the agency’s payment policy in the letter. In addition, the American Medical Association (AMA) has recognized modifier 26 is an appropriate mechanism to describe the PC of CP services for non-Medicare patients, the CAP letter stated.
Citing legal victories, the courts have been clear that pathologists through PC of CP services provide “valuable and compensable medical services,” the letter stated. The 1995 federal case Central States v. Pathology Laboratories of Arkansas rejected an insurer’s argument that pathologists do not provide services to hospital patients.
“The court also underscored pathologists being present or on call 24 hours and intervening to ensure a test is done right, recheck a surprising result, or interpret ambiguous data in support of its ruling in their favor on payment for their PC of CP services,” the CAP said.
CAP Urges CMS to Reverse Immunohistochemistry Pay Policy
The CAP discussed its concerns regarding Medicare payment for immunohistochemistry (IHC) services during a January 6 meeting with CMS officials.
The Affordable Care Act had provided CMS with expanded authority to launch its “misvalued code” initiative. CMS targeted the top expenditure codes from each specialty as potentially overvalued, which triggered the review of three additional high-volume code families. As a result, all specialties are facing downward pressures on Medicare payment.
The CAP discussed several reasons why CMS must reconsider and reverse its payment policy for IHC during the meeting. The CAP firmly stated assumptions used to create the G codes for IHC were flawed and the CAP opposed the rejection of new and revised CPT codes.
Furthermore, the CAP is willing to provide additional evidence that refutes assumptions by collecting data to support the use of the CPT codes together with the AMA /Specialty Society Relative Value Scale Update Committee (RUC) data. The CAP welcomed input from the agency on what data or information would assist in clarifying this matter.
“The CAP very much appreciated CMS sitting down with us for what was a productive meeting,” said Jonathan L. Myles, MD, FCAP, who chairs the CAP’s Economic Affairs Committee. “We continue to oppose CMS’ rejection of the new and revised CPT codes for IHC as these physician services are critical to personalized medicine. The benefits of the new and revised CPT codes include customization of immunohistochemistry markers used in the diagnosis and management of each patient’s condition.”
Discussions about the policy will continue with the CAP submitting formal comments on the Medicare fee schedule by a January 27 deadline.
MSNBC’s Matthews to Speak at CAP 2014 Policy Meeting
Veteran broadcast journalist Chris Matthews will address the CAP Annual Policy Meeting on May 6, 2014 in Washington, DC. One of television’s most recognizable political pundits, Chris Matthews offers intense curiosity, razor-sharp intelligence, and rapid-fire commentary on the American political scene.
Engage. Connect. Influence. Join your colleagues at the 2014 CAP Policy Meeting, May 5-7, 2014 in Washington, DC. Focus on the issues most important to pathologists now and in the future. Prepare yourself for what’s ahead and advocate on behalf of pathology on Capitol Hill. For pathologists, there’s no other meeting like it.
Patient and Physician Groups Endorse Legislation to Enhance Pathologist ACO Role
Physician and patient advocacy groups have now backed state legislation that would help ensure access to appropriate clinical laboratory and pathology services delivered in the accountable care organization (ACO) payment models in California (SB 264), Illinois (HB 2544) and New Jersey (AB 4302). The CAP and the respective state pathology societies are advocating for the legislation.
If enacted, at least one physician clinical laboratory medical director serving the ACO would be required to participate in newly created clinical laboratory testing advisory boards and recommend protocols for appropriateness of pathology and laboratory testing. The advisory boards would aim to ensure that patients have access to all medically necessary testing.
A 2012 CAP white paper illustrated pathology services’ value in collaborative care and also urged ACO adoption of clinical laboratory advisory boards to enhance ACO value and quality. Case studies featured in the white paper demonstrated ways pathologists add value to these organizations. The importance of pathologists in ACO partnerships is underscored when they analyze data related to patient testing and diagnosis, and offer evidence-based ways to achieve goals of improving health care quality and patient outcomes while reducing costs.
“These proposed bills benefit patients in ACOs by ensuring that any protocols for laboratory testing be optimally developed in consultation with the pathologist’s input,” said Kathryn Teresa Knight, MD, FCAP, who chairs the CAP Federal and State Affairs Committee. “As pathologists our medical expertise is integral to the success of the ACO by ensuring that patients, especially those with cancer, have full benefit of advances in molecular testing and other appropriate tests that can lead to swift and accurate diagnosis and optimal treatment.”
Two patient advocacy groups have endorsed the legislation. The Lung Cancer Alliance (LCA) expressed its support in a letter and noted lung cancer patients require care from medical teams that include pathologists. The National Brain Tumor Society (NBTS) stated in its endorsement that more than 600,000 Americans are living with a primary brain tumor and have complex health care needs.
“Pivotal to the diagnosis and treatment of brain tumor patients are laboratory tests,” NBTS stated in its letter. “Especially in the era of molecularly informed medicine, access, and availability of necessary laboratory tests are essential.”
Legislation in California, which is sponsored by the California Society of Pathologists, also has gained support of the California Medical Association (CMA). CMA wrote a Dec. 9, 2013, letter that emphasized the need for physician leadership in ACOs. CMA stated it believes physician-led ACOs ensure quality of care and patient interests as the highest priority.
“There needs to be a mechanism to review and establish parameters for routine clinical lab testing, but even more so for advanced testing like genetic testing and biomarkers for cancer treatment and therapy,” the CMA wrote in its letter.
National Quality Strategy Must Capture Value of Pathology, CAP Tells CMS
With current Medicare quality initiatives not an easy fit for many pathologists, the CAP called for more opportunities for physicians to demonstrate the specialty’s value in the National Quality Strategy in ways that match pathology’s scope of practice.
The CAP highlighted examples of quality programs and activities that contribute to improved patient care in a January 10 letter to CMS. The federal agency had asked for comments on the strategy after releasing its “Quality Strategy 2013-Beyond” in November 2013. The CAP letter detailed how pathologists have a role in each of the six priorities to the strategy: patient safety; patient and family engagement; care coordination; implementation of evidence-based prevention and treatment plans; population and public health; and more affordable quality care by developing and spreading new delivery models.
The strategy document can shape Medicare payment policy and quality programs. Currently, CMS initiatives, such as the Physician Quality Reporting System (PQRS), Value Based Modifier and Electronic Health Record Incentive programs, have not captured pathologists’ quality activities. Although pathologists, for example, can guarantee timely laboratory results and patient safety, they are unable to report such actions to CMS because specific PQRS codes or measures do not exist, said Diana Cardona, MD, FCAP, chair of the CAP Economic Affairs’ Measures and Performance Assessment Subcommittee. A notion in the strategy of offering quality incentives only to physicians demonstrating all six priorities would be impractical at this point and may not be possible in the future.
“We applaud CMS for doing this, but the all-or-nothing approach is not applicable to us,” Dr. Cardona said.
However, there are several opportunities to include pathologists in quality initiatives. The CAP letter has an appendix of illustrative examples of College-led quality programs. These include CAP Accreditation, Evalumetrics, CAP Proficiency Testing, and the Performance Improvement Program in Surgical Pathology.
“We also need to start thinking outside the box and create more ways we can fill the six quality domains,” Dr. Cardona said.
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