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April 23, 2019

In This Issue:

At the 2019 Policy Meeting, CAP members will go to Capitol Hill to advocate for policies that protect patients from surprise medical bills and ensure an accurate, market-based payment system for laboratories paid through the Medicare clinical laboratory fee schedule (CLFS).

The 2019 Policy Meeting begins April 29 and culminates on May 1 with pathologists discussing with congressional offices the importance of pathology in health care and the needs of patients. For 2019, CAP members will discuss their advocacy positions to hold patients harmless in surprise out-of-network billing situations and the need to improve data collection under the Protecting Access to Medicare Act (PAMA), which established a new methodology for the calculation of reimbursement rates under the CLFS.

Out-of-network bills occur when a patient’s insurance plan has not contracted with a physician, hospital, or other provider. During the 2019 Policy Meeting, CAP members will ask members of Congress to address surprise out-of-network bills by supporting legislative efforts that:

  • Hold patients harmless. Patients do not need additional financial stress when they are at their most vulnerable. Accordingly, patients should not be required to pay more for out-of-network physician services at in-network facilities when they cannot access an in-network physician.
  • Set network adequacy standards. Inadequate networks are the root cause of surprise bills. Without adequate networks of contracted physicians, a patient simply cannot be properly guarded from out-of-network health care at an in-network facility.
  • Offer fair reimbursement for care. To encourage health plans to contract physician services, and to ensure that a fair market rate should be paid for physician services.

On PAMA, pathologists will seek to remove Medicaid managed care from the definition of a “private payor.” Under PAMA, applicable laboratories are required to report private payor rates to the Centers for Medicare & Medicaid Services (CMS), which currently includes rates from Medicaid managed care organizations. While Medicaid managed care utilizes private health plans, rates from Medicaid managed care can be no higher than Medicare rates and can be lower depending on the state. These rates do not reflect market-based private payor rates and therefore should be excluded from collection and use in determining new rates.

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Max S. Baucus

On April 29, former US Ambassador and Senator Max S. Baucus will deliver a keynote address to pathologists participating in the 2019 Policy Meeting.

From 2014 to 2017, Mr. Baucus served as the US Ambassador to China. Prior to his ambassadorship, he served in the Senate from 1978 to 2014 and was Montana’s longest-serving senator. During his tenure, Mr. Baucus chaired the Senate Committee on Finance and also served as ranking member of the committee. As Chair of the Finance Committee, he led the passage and enactment of free trade agreements with 11 countries and authored the Affordable Care Act. He also was one of the conference committee authors of the Part D Medicare Prescription Drug law.

Currently, Mr. Baucus serves on the Board of Advisors for Alibaba, the Board of Directors for Ingram Micro, and the External Advisory Board for the Central Intelligence Agency. He is also co-chair of Farmers for Free Trade, a non-profit dedicated to supporting and expanding export opportunities for American farms and ranches.

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As part of the CAP’s ongoing efforts to educate policy influencers—members of Congress, congressional staff, regulatory agency officials, and health policy experts—digital advertisements will run in the Washington area starting April 22 through mid-May, including during the 2019 Policy Meeting.

The advertisements are intended to bring greater attention to the CAP’s advocacy on the issue of surprise medical bills. A core function of the CAP’s overall messaging is that pathologists have the right diagnosis on this issue and Congress must seek a legislative plan that holds patients harmless, establishes an arbitration process that leaves patients out of the middle, fixes narrow networks, and requires regulators to enforce network adequacy for health plans.

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