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- CAP Opposes Insurer Optum’s Move to Restrict 88305 Usage with Arbitrary Thresholds
The CAP has objected to the private insurer Optum’s new laboratory benefit management program and its efforts to establish limits on the number of CPT code 88305 units that will be reimbursed by specimen type. The CAP is seeking a meeting with Optum officials to further explain our position and to provide examples where it is common clinical practice to bill more 88305 codes.
The laboratory benefit management program seeks to address “inappropriate utilization” by limiting the number of CPT 88305 units that will be reimbursed by specimen type and automatically denying payment for “inappropriate add- on tests.” In a June 2 letter to Optum, the CAP said it is committed to addressing overutilization of testing, but policies or programs that interfere with a patient’s ability to receive timely and appropriate services/care risk negatively affecting patients, providers, and the entire health care system.
Pathologists are uniquely positioned to assist in adding value to patient care and controlling costs through application of evidence-based approaches, yet we have seen little detail on the clinical guidelines being used by the Optum [laboratory benefit management] or other details on how laboratory claims are evaluated,” the CAP said.
Restrictive policies do not account for the fact that pathologists and clinical laboratories do not control the number of specimens sent to them. It is the ordering physician that determines the number of specimens and the outlier providers who engage in overutilization who should be specifically targeted.