Read the Latest Issue of STATLINE

Citing concerns over Medicare contractors limiting and denying patients access to necessary pathology services, leading organizations representing pathologists have stated their strong support for the Local Coverage Determination Clarification Act (HR 5721).

The legislation, whose recent introduction in the House of Representatives was sought by the CAP, would increase transparency and accountability when Medicare Administrative Contractors (MACs) set local coverage determination (LCD) policies for Medicare beneficiary services. HR 5721 also would help ensure physician medical judgment and patient access to medically necessary care are not impeded.

The pathology organizations supporting passage of the bill are:

  • American Pathology Foundation
  • American Society for Clinical Pathology
  • American Society of Cytopathology
  • American Society of Dermatopathology
  • Association for Molecular Pathology
  • Association of Pathology Chairs
  • National Association of Medical Examiners

"Patients deserve to feel confident that medically necessary tests ordered by their doctor will be covered appropriately by Medicare regardless of where in the country they live", said Tristram Parslow, MD, PhD, the President of the Association of Pathology Chairs. "Our organization is grateful to CAP and members of Congress for sponsoring HR5721, which would improve access to testing and help ensure that different MACs implement CMS regulations fairly and uniformly."

"Too often the current coverage determination process takes place in the dark and neglects the input of physicians," said Samuel K. Caughron, MD, FCAP, chair of the Association for Molecular Pathology (AMP) Economic Affairs Committee. "AMP believes HR 5721 will improve the coverage determination process by ensuring transparency and accountability. It requires coverage policy to be based on appropriate medical evidence and requires MACs to provide a rationale for restrictions while publicly responding to stakeholder comments. HR 5721 is needed to guarantee good coverage policy for Medicare beneficiaries."

Reps. Lynn Jenkins (R-KS) and Ron Kind (D-WI) introduced the legislation in the House on July 11. The CAP supports HR 5721 and the principles contained in the legislation to improve the LCD process:

  • Open Medicare contractor committee meetings on LCDs
  • Upfront Disclosure of evidence considered during the drafting of an LCD
  • Meaningful reconsideration and options to appeal LCDs
  • Stopping the use of LCDs as a backdoor to National Coverage Determinations (NCDs)

Learn more about the CAP's position on this issue and download a CAP infographic about the LCD bill.

With Congress back in session on September 6, now is an opportune time to make your voice heard on the LCD bill. To send an email to your member of Congress today, visit the CAP Action Center.

Back to the top

Pathologists in the state of Washington are urging the state's insurance commissioner to adopt rules that ensure reasonable access to in-network providers at in-network hospitals and protect patients from ultra-narrow insurance networks that force them to avail out-of-network physicians, including pathologists. This summer, the Insurance Commissioner expressed interest in seeing legislation that would ban balance billing by out-of-network hospital-based physicians and tie out-of-network payments to a Medicare fee schedule.

The Washington State Society of Pathologists (WSSP), with support from the CAP, requested the Washington State Insurance Commissioner institute regulatory criteria for evaluating the sufficiency of hospital-based physician providers in health plan networks. The CAP and its members have strongly advocated for state regulators to adopt such requirements, while opposing state legislation and regulation to limit balance billing while failing to ensure patient access to in-network hospital-based physicians.

"We believe that adoption of the proposed regulation will further facilitate our mutual interest in ensuring that Washington State patients have reasonable access to in-network physician providers at in-network facilities and hospitals," wrote WSSP President Mohiedean Ghofrani, MD, MBA, FCAP, in an August 23 letter to the state insurance commissioner.

In the letter, Dr. Ghofrani referred to regulation in California that should be adopted in Washington.

In March, the state of California strengthened patient access to in-network pathologists by codifying requirements to ensure patients at in-network facilities have reasonable access to in-network hospital based-physicians. To receive approval, the California regulation requires health plans to submit a report describing the percentage of physician specialties at in-network facilities that are in the insurer’s networks. The physician specialties are emergency medicine, anesthesiology, radiology, pathology, and neonatology.

Insurers have resisted and opposed adoption of these rules. The WSSP urged the Washington State Insurance Commissioner to serve the public interest and "to ensure that consumers in the State of Washington are not misled into purchasing health insurance plan products that they believe can provide them with reasonable access to in-network physician providers at in-network facilities and hospitals."

Back to the top

Registration is now open for key CAP policy and advocacy courses and roundtable discussions important to the pathology specialty during CAP16 in Las Vegas September 25-28.

Ensure you can attend "MACRA, Pay for Performance and the Physician Fee Schedule—You Can Run But You Can't Hide" (S1620) by registering and selecting this popular course today. Enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) will change how all physicians are paid under Medicare. Make sure to attend this course and learn about this game changing mandatory Medicare physician payment system. Measurement periods begin in 2017 so register now so that you are ready for these changed to Medicare's physician reimbursement system.

During this featured presentation, attendees will learn the purpose of new pay-for-performance programs and delivery system reform culminating in the enactment and implementation of MACRA. Experts will explain which pathologists are subject to, and ways to successfully participate in, the merit-based incentive payment system and alternative payment model pathways. The potential ramifications for not participating will also be discussed.

The session starts at 8 AM on Monday, September 26. Register for S1620 MACRA, "Pay for Performance and the Physician Fee Schedule—You Can Run But You Can't Hide" today.

Additional CAP advocacy courses and roundtable discussions are also available at CAP16:

  • M1597 "How is My Payment Determined for Pathology Services?"
    Sunday, September 25, 4:30-5:30 PM
  • R1690 "My Surgical Pathology and Cytopathology Coding Dilemmas: Getting It Right"
    Monday, September 26, Noon-1 PM
  • STA001 "How Data Drives CAP Advocacy: What Pathologists are Saying about the Economics of Pathology Practice"
    Monday, September 26, 5:30-6:30 PM
  • R1691 "Current Payment Policy Challenges in Pathology Practice"
    Tuesday, September 27, Noon-1 PM

Back to the top

Joe Saad, MD, FCAP

Each month, STATLINE will feature one of the many CAP members who have been champions for pathology in Washington and at the state level through our grassroots and PAC programs. If you would like to get involved, you can join PathNET, contribute to PathPAC, or join your state pathology society.

Name: A. Joe Saad, MD, FCAP
Position: Chairman of Pathology, Methodist Health System, Dallas, Texas

How did you first get involved in advocacy with the CAP?

I first got involved with advocacy through the Texas Society of Pathologists (TSP). About ten years into my career, I realized that signing out cases and my involvement in the hospital lab was not enough. Decisions about how I practice, our future, and the welfare of our patients were being made in board rooms and legislatures far away from our laboratories and offices. I decided that I wanted to have a voice in the process. I became an active member in TSP and chair of the Council on Legislation. I definitely recommend getting involved with your state pathology society. If you have an active society, that's great. If not, that may be even better because the opportunity exists for you to make a greater impact by reviving it. It takes effort, but the reward makes it worthwhile.

From there, I went to Advocacy School (the predecessor to CAP’s Policy Meeting) and made several trips to Capitol Hill to meet with legislators and their staff. Hill Day in Washington, DC, is always a thrill. On a nice day in DC, it is a great place to be. Even a bit of rain doesn’t dampen my enthusiasm! It's exciting and rewarding to participate in our great democracy. While change is slow and decisions may not always go our way, I am grateful that the CAP and its members are engaged in advocating for pathology and our patients.

Why is advocacy important to you?

Advocacy is important to me because I love what I do. Pathology is the best profession, and I'm excited about my daily work and making a difference in my hospital and for our patients. In order to ensure that our future is secure, we need to advocate for ourselves. We can’t rely on anyone else to do this critical job. Collectively, we must ensure that the profession is strong and the future is bright. Advocacy occurs at many levels. Most people tend to think of it as Washington, DC, politics and federal regulations, but many critical decisions are made at the state level by state legislators and regulators. Also, we must keep in mind that we must advocate for our patients and laboratory within our own institutions. We must be involved in hospital committees and establish relationships with doctors across all specialties and administrators at all levels. Take on projects that require you to step out of your comfort zone and into areas in the hospital that are not directly laboratory-related. Our survival as individuals and as a profession depends on it.

What do you find most rewarding and/or most challenging about being an advocate for pathology?

The most challenging aspect of advocacy can be the complexity of the issues we have to deal with. PAMA, MACRA, LCDs, and LDTs are big, complex policy issues with numerous stakeholders involved from many different perspectives and with a multitude of opinions. Of course, the bigger the challenge, the bigger the potential reward. Unfortunately, victories are frequently small and measured. So often the reward is being involved in the process and knowing that you have been heard. Last week, I had the opportunity to meet with my Congressman, Pete Sessions, at his district office. We discussed a broad range of health care-related issues for over an hour. He pledged to sign on as a cosponsor of the CAP’s LCD bill, and invited me to attend a town hall meeting and join his health care advisory committee.

It's never too early or too late to get involved. You can establish relationships with state and federal legislators by visiting them in their district offices, attending fundraisers, and emailing them when you get an action alert from CAP. We need to build support one step at a time, to push forward and each do our small part. Collectively, we can accomplish so much more.

Back to the top

STATLINE will take a scheduled break on September 6 due to the Labor Day holiday. The next regular edition of STATLINE will be published on September 13. If major news breaks before September 13, CAP members will receive a STATLINE Special Report with news also published on the CAP's Twitter and Facebook feeds.

Please email STATLINE's editor if you have questions or comments.

Back to the top