Advocacy Update

Read the Latest Issue of Advocacy Update

August 18, 2020

In this Issue:

CAP Objects to UnitedHealthcare Test Registry Requirements

Following an announcement from UnitedHealthcare to require laboratories to register all tests in its registry in order to bill for services next year, the CAP will object to the implementation of the registry as pathologists and their laboratories cope with the COVID-19 pandemic.

UnitedHealthcare sent a communication last month to laboratories that free standing and outpatient hospital laboratories that delayed the need to register their tests to December 1, 2020. Initially, laboratories were to meet an October 1 deadline but UnitedHealthcare delayed the requirement because of the pandemic. After a laboratory registers its tests, the laboratory will receive a unique test code.

Starting January 1, 2021, all applicable clinical and pathology claims must contain the laboratory’s unique test code. Otherwise, the insurer said it will deny claims without the test code. The change affects all UnitedHealthcare commercial, Medicare Advantage, and most community plan networks.

The CAP is engaged on the new reimbursement policy and is reaching out to UnitedHealthcare’s leadership with its concerns. The various challenges the current pandemic presents to laboratories will likely continue through the beginning of 2021. Now is not the time to move forward with new billing rules and potentially further disrupt revenues by denying claims for tests.

The CAP will provide additional updates on this issue as they develop. Read more updates on the CAP’s Advocacy concerning private health plans on our website.

CAP Secures Clarification on COVID-19 Test Prices from PA Insurance Department

In a response to the CAP and its advocacy, the Pennsylvania Insurance Department recognized there will be variability in prices for COVID-19 tests and the department will focus its consumer protection efforts on anomalous billing that insurers may encounter.

On August 6, the CAP took issue with a Pennsylvania Department of Insurance notice that said some laboratories in the state charged amounts for COVID-19 tests in excess of their costs and, in some instances, may be considered improper. The CAP expressed its concern that the state’s warning went against the federal Coronavirus Aid, Relief and Economic Security (CARES) Act and the law’s pricing provision for out-of-network SARS-CoV-2 testing. Under the law, "if the health plan or issuer does not have a negotiated rate with such provider, such plan or issuer shall reimburse the provider in an amount that equals the cash price for such service as listed by the provider on a public internet website, or such plan or issuer may negotiate a rate with such provider for less than such cash price."

The CAP said some laboratories are charging different amounts for COVID-19 tests, and in some cases, excess the amount of the actual test cost. The market value pricing for COVID-19 testing is highly variable and dependent upon multiple input costs, the CAP said. When comparing private prices to Medicare payment rates it is important to note that these costs are not addressed in Medicare pricing. These payment rates were set without access to costs and charges for the test, and the Medicare Administrative Contractors (MACs) have not provided any methodology used to establish their rates.

The CAP asked the state insurance department clarify the focus of their concern for out-of-network COVID-19 testing so that “clinical laboratories billing for COVID19 testing in the conventional range of market-based charges can avail the stated payment methodology of federal law.”

The department responded in writing on August 13 and said the department recognizes that there will be some price variability in the current market for COVID-19 tests.

CMS Launches Test of Potential MIPS Cost Measures on August 17

The Centers for Medicare & Medicaid Services (CMS) will test potential new measures for future use in the Merit-based Incentive Payment System (MIPS) Cost category. Field testing of these measures will begin on August 17. To date, most pathologists have not been attributed to any Cost category measures and have had their Cost category automatically reweighted to the Quality category. The CAP will monitor the results of the upcoming test and further engage with the CMS regarding any concerns with potential Cost measures on behalf of its members.

The CMS plans to use a contractor, Acumen, LLC, to conduct its field test for the following five episode-based cost measures before further consideration of their potential use in the Cost performance category.

  • Asthma/Chronic Obstructive Pulmonary Disease (COPD)
  • Colon and Rectal Resection
  • Diabetes
  • Melanoma Resection
  • Sepsis

Field test reports for eligible clinicians and clinician groups will be available through the Quality Payment Program (QPP) Portal starting August 17 through September 18. We encourage you to log in to the QPP website with your QPP credentials to check if you have received one or more field test reports. If you receive a field test report for a cost measure, please attribute it to that cost measure if implemented in the future as an MIPS cost measure.

For more information about field testing, you may review the following educational materials currently available on the MACRA Feedback Page.

How to Provide Your Feedback

The CMS is seeking feedback from all clinicians and stakeholders. You can provide feedback on the draft measure specifications through this online survey, which will open at the start of field testing. A document containing specific questions about the measures for stakeholders to reference while reviewing the materials will be available on the MACRA Feedback Page.

The CMS said stakeholder feedback on all the cost measures is vital in the measure refinement process, and the agency hopes you will consider sharing your input.

If you have any questions or require assistance, please contact the Quality Payment Program Service Center via telephone at 1-866-288-8292 or via email at

Missed Our Medicare Fee Schedule Webinar? Watch the Recording

The CMS released proposed the 2021 Medicare Physician Fee Schedule and the Quality Payment Program regulations. The CAP hosted a webinar where experts reviewed the proposed regulation changes that will impact your pay, practice, and participation in the Merit-based Incentive Payment System (MIPS).

Missed the webinar? Check out the recording and download the slides.

Check out the August Advocacy News Quiz

Take this month’s Advocacy News Quiz and see how many questions you can get right. Last month over 100 CAP members took the July news quiz. See how you compare against your fellow CAP members’ in this month.

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Breaking Advocacy News: Check out the Advocacy Twitter Channel

Want up to the minute CAP Advocacy news? Then follow us on twitter at CAPDCAdvocacy, where you will be the first to know about CAP Advocacy wins, see your fellow members engage with Congressional leaders on key policies affecting the practice of pathology and, of course, breaking Advocacy news.

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