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The CAP's state advocacy efforts help to secure the Centers for Medicare and Medicaid Services (CMS) requirement for insurers who participate in federally-facilitated health insurance exchanges to document their process for monitoring access to hospital-based physicians, including pathologists, at in-network hospitals.

This language, advocated by the CAP, is included in the 2018 Qualified Health Plan (QHP) Application for those health plans applying to participate in the federally-facilitated Marketplaces. In 2017, there were 28 federally-facilitated exchange marketplaces operating in the states.

Specifically, the application requires health insurance carriers to document their, "process for monitoring access to physician specialist services in emergency room care, anesthesiology, radiology, hospitalist care and pathology/laboratory services at their participating hospitals." The CAP had developed the regulatory/legislative language and successfully advocated it at the National Association of Insurance Commissioners (NAIC) in 2015, in order to require insurers to document their practice for monitoring access to hospital-based physicians at in-network hospitals and report it to state oversight regulators. Unexpectedly, the CMS incorporated the NAIC backed state oversight standard into their 2018 QHP application process for the federally-facilitated health insurance exchanges.

By requiring insurance carriers to report to the federal government their practice for monitoring access to hospital-based physician specialists, federal regulatory scrutiny of the network adequacy of QHPs will explicitly extend to hospital-based physicians for the first time in the history of the program. Network adequacy is the ability of a health plan to provide its participants/patients a sufficient number of in-network providers, including primary care and specialty physicians, such as pathologists, as well as other health care services, that are included in the insurance plan for patients. The inclusion of this standard in the 2018 QHP application for the federally-facilitated exchanges is a direct result of the CAP lead advocacy on network adequacy at the NAIC.

For more information on network adequacy and out of network billing, please register for the Network Adequacy in Health Plans: The Financial Implications for Pathologists webinar on August 22 at 1 pm ET.

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On August 1, the CAP helped to secure the re-introduction of Local Coverage Determination Clarification Act of 2017 in the US House of Representatives. The bill would improve transparency and accountability when Medicare contractors set local coverage determination (LCD) policies for physician services provided to Medicare beneficiaries. This bill, in conjunction with the Senate version that was introduced in March 30 of 2017, highlights the CAP's advocacy efforts to increase transparency and accountability in reforming Medicare's LCD process.

The CAP applauds Reps. Lynn Jenkins (R-KS) and Ron Kind (D-WI) for introducing this fundamental piece of legislation for physicians and patients on August 1 who have been working with the CAP on improving the LCD process for patients. The House bill, together with the Senate version of the bill that was introduced on March 30, will pave the way for much needed LCD reform.

"Essential changes to this existing legislation would guarantee that Medicare local coverage determinations do not impede a physician's medical judgment and deny patients access to crucial medical care. The House bill would certify that coverage decisions are made by experienced, independent health experts through a transparent process that is based on sound medical evidence,"" said CAP President Richard C. Friedberg, MD, PhD, FCAP. "The CAP appreciates that Representatives Jenkins and Kind introduced this significant legislation in the House on behalf of patients and the physicians who treat them."

In addition, the CAP leads a coalition of 122 physician and industry organizations who also support this bill, that include Advanced Medical Technology Association, American Medical Association, American Society of Clinical Oncology, American College of Cardiology, the Amputee Coalition, as well as state pathology organizations.

The CAP developed a LCD infographic explaining the key provisions of the legislation.

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

Check out the full list of Advocacy courses offered at CAP17.

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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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David Gang, MD, FCAP

No matter what kind of practice setting is in your future, health policy and payment models will impact you and your practice. On Wednesday, August 9 at 1 PM (ET), the CAP will host an Advocacy webinar on what residents need to know about reimbursement policies and how advocacy plays a vital role in your pathology practice livelihood.

During this 60-minute informative webinar, you will learn about the College of American Pathologists (CAP) advocacy and policy agenda, and how it directly impacts all residents and pathologists.

Kelsey McHugh, MD

Led by David Gang, MD, FCAP, Vice-Chair of the CAP’s Federal and State Affairs Committee, and Kelsey McHugh, MD, junior member of the CAP's Federal and State Affairs Committee, attendees will learn about health policy basics and the importance of getting involved in CAP initiatives that helps to advocate for patients.

Register today.

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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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