Advocacy Update

August 23, 2022

In this Issue:

Final Surprise Billing Regulation Outlines Updated Billing Dispute Settlement Process

On August 19, the Biden administration released the Requirements Related to Surprise Billing final rule, which follows a court decision supported by the CAP that struck down part of an earlier policy related to the independent dispute resolution (IDR) process. The final regulation instructs arbiters to consider an insurer's median contracted in-network rate and any additional information – including physician training and experience, patient acuity, and more – when determining the correct payment for a surprise bill. Further, the agencies make a point to avoid double-counting information, and the arbiter should not give weight to information related to a factor if the certified IDR entity determines the information was already accounted for in the calculation of the qualifying payment amount.

The CAP, the American Medical Association (AMA), and many other provider groups had warned that the initial requirements for the IDR process heavily favored insurers and would cause substantial harm to physicians. While the final regulation makes some improvements over the initial regulations, the CAP evaluates the final rule to ensure the new IDR requirements provide a fair system where physicians and health insurers can resolve disputes without one factor having more weight than another.

Pathologists Urge Revised Network Adequacy Rulemaking in Maryland

The Maryland Society of Pathologists (MSP) and the CAP enlisted with other physician specialties and the Maryland State Medical Society (Med-Chi), to urge amendments to a proposed state Insurance Department network adequacy regulation that omitted any consideration of network adequacy criteria for hospital-based physicians. The draft rule removed previously proposed criteria, issued for public comment in 2020, assessing health plan network adequacy with an explicit determination of whether health plans had contracted with hospital-based physicians, laboratories, and radiological facilities. The revised rules were reviewed at a public departmental hearing on August 15, 2022, in which the CAP testified on behalf of MSP in support of the Med-Chi letter.

The physician coalition, comprised of pathology, radiology, emergency medicine, and anesthesiology, led by Med-Chi urged the agency to revise the draft to include a requirement on health plans to "maintain a network in sufficient number, geographic locations, and practicing specialties, including timely on-site access to emergency services, on-call physicians and hospital-based physicians." The coalition cited existing Maryland regulations defining a hospital-based physician as "an anesthesiologist, pathologist, radiologist, neonatologist, hospitalist, intensivist, or emergency medicine physician that practices exclusively within an accredited hospital and provides care to enrollees only as a result of the enrollees being directed to the hospital."

The coalition affirmed, “lastly in referencing hospital-based physicians, it is important that we acknowledge that some of these providers are not only “hospital-based” but practice across multiple settings and should be accounted for under network adequacy sufficiency standards. The Administration must ensure that carriers are evaluating and reporting sufficiency for those specialties that work not just in hospitals but across other settings and that they are being accounted for in the standards."

To date, the CAP has worked with state pathology societies and state medical associations to secure the enactment of network adequacy laws that require health plans to be evaluated for enrollee access to hospital-based physician specialists, specifically inclusive of pathologists, in Virginia, Washington, New Hampshire, Virginia, and Louisiana. In addition, other states, like West Virginia, as the result of the CAP’s advocacy, have laws to require health plans to report their processes for monitoring enrollee access to hospital-based physicians, including pathologists.

The CAP will continue to work with MSP and the coalition to secure favorable network adequacy regulations.

Good Faith Estimates Resources for Pathologists

Earlier in 2022, the Centers for Medicare & Medicaid Services (CMS) released good faith estimate requirements. To help members understand the good faith estimates and price transparency for diagnostic medicine, the CAP has resources, including a toolkit and a podcast.

The CAP recorded the good faith estimate requirements podcast with Theresa Emory, MD, FCAP. Dr. Emory discussed how the requirements affect pathologists. A good faith estimate provided to uninsured (or self-pay) individuals must include an itemized list of all items or services that are reasonably expected to be furnished for that period of care, grouped by each provider or facility.

Check out the resources and podcast.

In Case You Missed It: The CAP Perspective on the VALID Act Webinar

In case you missed the CAP Perspective on the VALID Act webinar, you can watch the recording to get the latest information on the CAP’s lobbying efforts to enact legislation for a new comprehensive regulatory framework for laboratory-developed tests (LDTs) and our regulatory policy requests.

Watch the recording

Test Your Advocacy News Chops

Think you know CAP Advocacy facts - then test your knowledge with the August Advocacy News Quiz. Last month over 70 members took the quiz. See how you compare against your fellow CAP members and brag about your top scores on social!     

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