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The CAP continues to engage with UnitedHealthcare and oppose the insurer's laboratory benefit management pilot program in Florida. The CAP has urged UnitedHealthcare to not move forward with the pilot program's full implementation on April 15 because it will negatively affect patient access to services, delay results, and create inconsistencies with current clinical practice, professional judgment, and laboratory operations.

Most problematic for laboratories will be the pilot program's denials for claims due to no fault of their own. Laboratories will be denied payment for services when ordering physicians do not comply with the pilot's requirements.

The CAP has engaged with UnitedHealthcare and expressed these concerns with the pilot that requires use of Beacon Laboratory Benefit Solutions (BeaconLBS). The pilot program now affects 79 laboratory services ordered by Florida network providers for patients insured by most fully insured UnitedHealthcare commercial members in the state. UnitedHealthcare will deny claims for laboratory services in Florida when the pilot's requirements are not followed starting April 15.

In addition to claims denials to laboratories scheduled to begin April 15, fundamental flaws in the pilot's second review requirements are extremely concerning. Under standard practice, pathologists make decisions on a daily basis based on their professional judgment and training when to seek secondary reviews and who should provide them, based upon the patient's actual specimen, rather than as dictated by the insurance company.

The CAP strongly objects to the pilot's interference with medical judgment and new administrative burdens created by UnitedHealthcare. The Florida Society of Pathologists, several organizations, and medical associations representing ordering physicians have objected to the program due to its clinical and operational implications.

Before the initial intended full launch of the program in October 2014 and again at the end of 2014 before the revised full launch date of January 1, 2015, UnitedHealthcare had published notices about a decision to delay enforcement of the pilot program. A delay in claims denials had been in place since the initially intended October 1, 2014 effective date. Prior to that date, the CAP had several discussions with UnitedHealthcare and formally requested the insurer suspend its planned implementation of the pilot program.

The CAP continues to advocate with UnitedHealthcare on behalf of pathologists and will continue to keep members advised of developments in STATLINE.

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The Centers for Medicare & Medicaid Services (CMS) has taken steps to limit the impact of the 21% sustainable growth rate (SGR) cut to Medicare payments for physician services as the Senate plans to vote on legislation to permanently repeal the broken formula.

The negative SGR cut technically took effect on April 1 after Congress missed the deadline to enact pay fix legislation. The House had passed the Medicare Access and CHIP Reauthorization Act (HR 2) on March 26, but the Senate did not vote on the measure. The Senate is expected to consider the bill once it returns from a scheduled recess on April 13. The legislation includes a provision secured by the CAP that would give pathologists flexibility to achieve requirements in Medicare quality initiatives. CAP language in the bill would be tied to a new Merit-based Incentive Payment System.

With Congress missing a deadline to fix the SGR, the CMS announced it would not process physician claims and pay fees for Medicare services with the 21% cut immediately. The CMS will hold claims for at least 14 days.

"Holding claims for a short period of time allows CMS to implement any subsequent Congressional action while minimizing claims reprocessing and disruption of physician cash flow in the event of legislation addressing the 21% payment reduction," the agency stated on April 1. "Under current law, electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. As we stated in our recent email to physicians, CMS will provide more information about next steps by April 11, 2015."

Claims for services furnished on or before March 31, 2015 are not affected by the payment cut. These claims are being processed and paid under normal time frames. "We are working to limit any impact to Medicare providers and beneficiaries as much as possible," the CMS added.

The CAP will continue to keep members informed on the latest SGR developments through STATLINE.

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The May 4-6 Policy Meeting is an opportunity for pathologists to act as an advocate for their practice and patients. With less than 30 days remaining until the 2015 CAP Policy Meeting, there is no better time to act and make your voice heard.

Register today to engage with nationally recognized experts, connect with other colleagues within your practice, and influence issues that are impacting the pathology practice. On May 6, CAP members will visit with lawmakers during the CAP's Annual Hill Day. Pathologists will educate lawmakers and seek their support on vital public policy issues that impact the specialty. This is a unique opportunity to personally advocate for improving patient care and the practice of pathology.

The meeting also will feature health policy influencers, including former CMS Administrator Don Berwick, MD, FDA Office of In Vitro Diagnostics Director Alberto Gutierrez, PhD, and CMS Hospital and Ambulatory Payment Group Director Marc Harstein. CAP members also will hear from Pulitzer Prize winning columnist George Will during a keynote speech. Registration is open to all CAP members.

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