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August 16, 2017

In This Issue:

The CAP and other members of the Coalition of Hospital-Based Physicians are urging the Maryland Insurance Department to amend a proposed network adequacy rule to ensure it includes critical hospital-based physician specialties.

The proposed rule, published July 21, does not include pathology, anesthesiology, emergency medicine, radiology and radiation oncology as medical specialties that are to be evaluated for health plan network adequacy at hospitals.

"This omission is fundamentally inconsistent with the public policy objective of network adequacy: to ensure that Maryland patients have access to high volume in-network physicians under their plans of insurance," says the coalition in comments submitted August 3 to Al Redmer Jr., the Maryland Insurance Commissioner.

The coalition further notes that the 2015 national model legislation/regulation on network adequacy developed by the National Association of Insurance Commissioners (NAIC), placed a clear obligation on health insurance payers to declare, as part of their submission to the state, their "process for monitoring access to physician specialist services in emergency room care, anesthesiology, radiology, hospitalist care and pathology/laboratory services as their participating hospitals."

A number of states, including California, Oregon, Colorado and Connecticut have already adopted network adequacy provisions that specifically include the physician specialties address by the NAIC in its model regulation, says the coalition. The Maryland proposed rule does not follow the NAIC recommendations, and is also contrary to the American Medical Association's policy on network adequacy, which says health plans should be required to document to regulators that they have met requisite standards of network adequacy, including hospital-based physician specialties (i.e., radiology, pathology, emergency medicine, anesthesiologists and hospitalists) at in-network facilities and ensure in-network adequacy is both timely and geographically accessible.

The CAP and other members of the coalition recommend that the Insurance Department amend the proposal to require a report describing, for each network hospital, the percentage of physicians in each of the specialties listed above practicing in the hospital who are in the insurer’s networks. This will help ensure that enrollees have reasonable and timely access to these in-network physicians, notes the coalition.

The CAP will continue to follow developments on this proposal.

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The CMS Quality Payment Program announced its Hardship Exception Application for the 2017 transition year is now available. The CAP strongly advocated to secure automatic exemptions for pathologists from this category of Merit Based Incentive Program or (MIPS) and the vast majority of pathologists will not be required to report in this category of MIPS.

MIPS eligible clinicians (ECs) who are considered Special Status, will have their Advancing Care Information category score automatically reweighted. These ECs include those pathologists who are considered non-patient facing or are hospital-based. In addition, pathologists participating in a MIPS APM will not need to submit a Quality Payment Program Hardship Exception Application. However, due to the program's rules, a small number of pathologists may need to apply for the hardship exception. The CAP encourages you to check on your Special Status.

MIPS defined ECs and groups who may qualify for a reweighting of their Advancing Care Information performance category score to 0% of the final score, and can submit a hardship exception application, for one of the following specified reasons:

  • Insufficient internet connectivity
  • Extreme and uncontrollable circumstances
  • Lack of control over the availability of Certified EHR Technology (CEHRT)

For more information about the Quality Payment Program hardship application process, visit the Quality Payment Program website.

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Reserve your seat at featured Advocacy Courses

Registration is now open for key CAP policy and advocacy courses and roundtable discussions important to the pathology specialty during CAP17 at the Gaylord National Harbor from October 8–11, 2017.

Learn about the new Pathologists Quality Registry and how it can help you comply with the Quality Payment Program in 2017 during the Optimize Your Medicare Bonus Potential with the Pathologists Quality Registry session on Monday, October 9.

Additional CAP advocacy courses and roundtable discussions are also available at CAP17:

  • M1596: How is My Payment Determined for Pathology Services?
  • R1690: My Surgical Pathology and Cytopathology Coding Dilemmas
  • R1691: Current Payment Policy Challenges in Pathology Practice
  • S1620: Medicare's New Quality Payment Program and the Physician Fee Schedule

Moreover, hear about the current trends in Pathology Practice and how it shapes CAP Advocacy efforts.

  • STA007C: Results from the 2017 CAP Practice Characteristics Survey

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Diana Cardona, MD, FCAP

On August 31 at 1 PM ET, the CAP will host a 30-minute webinar presentation specifically on Medicare's Merit-based Incentive Payment System (MIPS) and how it applies to pathology practices. During this complementary program, you will learn about Medicare's new reimbursement program and how pathologists can participate. The MIPS program is part of the new Medicare Quality Payment Program stemming from the 2015 Medicare Access and CHIP Reauthorization Act (MACRA). Beginning this year, the MIPS will set future Medicare payments based on categories that include quality and clinical practice improvement activities. Success in these categories can earn physicians higher Medicare reimbursements.

Register for the webinar, Making Sense of Medicare's MIPS Program, today.

Our presenter Diana Cardona, MD, FCAP, will discuss how pathologists can participate in MIPS in 2017 and 2018. Dr. Cardona, who chairs the CAP Economic Affairs Committee’s Measures and Performance Assessment Subcommittee, will review which quality measures and activities are relevant to pathologists, as well as which options pathology practices can use to submit performance data for MIPS scoring. These scores will determine whether physicians receive bonuses or penalties.

At the end of the presentation, Dr. Cardona will answer your questions. If you cannot attend the live portion of this webinar, it will be recorded and those who register will automatically receive a link to view the archived recording once it is available.

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CAP Members from top to bottom, Joe Saad, MD, FCAP; David Gang, MD, FCAP; Robert P. DeCresce MD, FCAP; Patrick Godbey, MD, FCAP

Provider network adequacy and balance billing influence the market value of pathology services, regardless of whether a pathologist is an employee or an independent contractor.

In recent years, state regulators have failed to ensure health plans maintain robust networks of physicians as insurers created narrow and "ultra-narrow" networks of providers.

The CAP has strongly advocated for state regulators to protect patients from health plans with inadequate networks of pathologists and other hospital-based physicians.

During this 60-minute informative webinar on August 22, 2017, at 1 PM ET, you will learn more about the CAP's state advocacy strategy and how you can get involved.

Led by Joe Saad, MD, FCAP, Chair of the Federal and State Affairs Committee (FSAC), David Gang, MD, FCAP, FSAC Vice-Chair, and Robert P. DeCresce MD, FCAP, FSAC Member, and moderated by Patrick Godbey, MD, FCAP, Chair of CAP Council on Government and Professional Affairs, CAP attendees will learn about network adequacy and balance billing issues facing pathologists and the financial impact on pathology practices.

Register today.

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The CAP invites readers to take a quick survey regarding STATLINE, our weekly federal and state advocacy e-newsletter. STATLINE strives to keep CAP members updated on the latest regulatory and legislative issues concerning pathologists at the federal and state levels of government. Through news briefs, STATLINE provides clarity on these issues while also reporting what the CAP is doing to address matters concerning pathologists. Your valuable feedback will allow us to evaluate and improve the e-newsletter to best meet your needs. This survey should take approximately 5–10 minutes to complete.

Take the STATLINE Readership Survey.

The CAP recognizes the value of your time and privacy. Be assured that your individual information will be kept strictly confidential and your email address will not be distributed to anyone. All results are reported in aggregate format. If you need assistance, please email Lori Vernon at:

As a thank you for your time and feedback, we invite you to enter into a drawing to win one of three $100 gift cards. If you would like to enter, please enter your information at the end of the study.

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STATLINE will take a scheduled break on August 22 and will next appear in your email inbox on August 29. Please continue to check the CAP Twitter and Facebook accounts for updates from the CAP.

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