Advocacy Update

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February 11, 2020

In This Issue:

The House Ways and Means Committee released legislation, the Consumer Protections Against Surprise Medical Bills Act of 2020, on February 7 that features provisions advocated for by the CAP to resolve billing disputes between insurers and physicians. The inclusion of an open mediation, or an independent dispute resolution, process without a minimum threshold to access an arbitrator has been a key request specifically lobbied for by the CAP.

Ways and Means officials said the legislation puts patients first by protecting the patient from balance bills, enhancing consumer protections, requiring greater transparency, and empowering patients with information about their health care costs—which are all points also supported by the CAP. The Ways and Means Committee was scheduled to further debate and amend the bill on February 12. The bill is expected to be voted on and approved by committee members with overwhelming support.

Lawmakers from other House committees have also stated their support for the Ways and Means’ proposal. Reps. Phil Roe, MD (R-TN), Joseph Morelle (D-NY), Van Taylor (R-TX), and Donna Shalala (D-FL), who all sit on the House Education and Labor Committee, issued a news release in support of Ways and Means bill. Hospital organizations, such as the Federation of American Hospitals, and other physician associations, such as American College of Emergency Physicians, also were encouraged by the Ways and Means bill language.

Other legislative proposals introduced and debated by the Senate Health, Education, Labor, & Pensions Committee, House Energy and Commerce Committee and, more recently, the House Education and Labor Committee have favored insurance companies and have fallen well short of taking a balanced approach to eliminating surprise medical bills. Their proposals rely on rate-setting based on median in-network rates that remove any incentive for insurers to negotiate in good faith and may lead to even narrower insurer networks of physicians. The CAP strongly opposes these other proposals.

Urge Your Representatives to Act on Surprise Bills

Go to the CAP’s action center to tell your representatives in Congress to support our positions on surprise medical bill legislation. Enter your email and ZIP code to login and select the legislative alert on surprise billing. In just a few clicks, you can easily communicate with your elected officials.

Despite the outbreak, public health laboratories will not be immediately ready to test for the corona virus. On February 8, the Centers for Disease Control and Prevention (CDC) said that even though the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel, public health laboratories will not be immediately ready until they complete their test performance verification processes.

The CAP will work with the CDC to monitor the outbreak and laboratory capacity to provide testing. The CAP will provide further updates as new information becomes available.

Since the identification of the virus, US diagnostic testing for 2019-nCoV was only conducted at the CDC. However, with the EUA determination and the pursuant distribution of the tests, 2019-nCoV diagnostic testing can now also take place at laboratories designated by the CDC. These US laboratories are qualified and certified under CLIA to perform high-complexity tests. These laboratories include 115 US state and local public health laboratories and Department of Defense laboratories. The CDC 2019-nCoV RT-PCR Diagnostic Panel will not be available in US hospitals or primary care settings.

The CDC 2019 novel coronavirus diagnostic test is intended for use with upper and lower respiratory specimens collected from people who meet CDC criteria for 2019-nCoV testing.

Clinical laboratories should not attempt viral isolation from specimens collected from 2019-nCoV patients under investigation (PUIs). For interim guidelines for collecting, handling, and testing clinical specimens from PUIs for 2019-nCoV, please see the CDC 2019 Novel Coronavirus website.

Trump Administration Releases Key Points for Laboratories

In response to the novel coronavirus (2019-nCoV) outbreak, the Department of Health and Human Services Secretary Alex Azar declared a public health emergency on January 31.

While no FDA-approved tests are yet available in the United States to detect or diagnose 2019-nCoV in clinical specimens, the CDC developed a molecular in vitro diagnostic test based on widely used nucleic acid amplification technology. The Centers for Medicare & Medicaid Services (CMS), which is an agency under the HHS, released the following key points for laboratories:

  • The CDC 2019-nCoV assay is for use by CDC-qualified laboratories.
  • Like all assays issued an EUA, this assay is subject to CLIA.
  • Upon receipt of the assay, CDC-qualified laboratories must verify performance specifications on-site and follow all other manufacturer’s instructions.
  • The CMS encourages laboratories to evaluate assay performance further as testing continues, and more positive specimens become available.

After implementing some improvements advocated by pathologists to Medicare’s local coverage determination (LCD) process, the CAP closely monitored the changes and its impact on coverage policy development. As a result, the CAP and its members have noted opportunities for improvement to encourage meaningful feedback and dialogue between pathologists and Medicare contractors.

In a letter sent to the CMS on February 4, the CAP detailed six recommendations to improve CMS’ Contractor Advisory Committee (CAC) meetings and the LCD process. These meetings are critically important for pathologists to discuss coverage issues, provide testimony, and ask questions about coverage policies before they are drafted and ultimately go into effect for Medicare beneficiaries. In previous years, the CAP lobbied to make these meetings more open, including instituting a requirement for providing summaries of evidence and rationale that supports draft LCDs. These changes are now reflected in Medicare’s Program Integrity Manual for its contractors to follow.

The February 4 letter followed a meeting between the CAP leadership and the CMS on how to improve the CAC forums further. While some Program Integrity Manual changes have increased transparency, new CAC meeting formats lack valuable interaction between stakeholders. Specifically, the CAP urged the CMS to offer pathologists a more meaningful opportunity to discuss the realities of their practices within local jurisdictions.

The CAP recommended that the CMS:

  1. Reestablish CAC meetings as a venue for CAC members to share their relevant expertise and evidence as technical subject matter experts.
  2. Require Medicare Administrative Contractors to hold CAC meetings for to solicit CAC consultation before the development of new LCD policies.
  3. Require MACs to select CAC meeting times that offer the greatest opportunity for participation.
  4. Give CAC participants more time and meaningful context to review materials prior to meetings.
  5. Provide meeting materials with specific hypothesis, rationale, and/or proposal for coverage or noncoverage policies under consideration, rather than providing a bibliography of evidence without necessary context.
  6. Improve audio technology for teleconference meetings.

The CAP actively engages with pathology CAC representatives, the MACs, and the CMS on local and national coverage determinations. The CAP will continue to engage with the CMS on important issues related to Medicare LCD reform.

A critical measure designed to address health plan network adequacy by giving patients more information about hospital-based physicians in their insurance network passed the Georgia House Special Committee on Access to Quality Health Care February 3. The bill is strongly supported by the Georgia Association of Pathologists (GAP) and the CAP.

HB 789 would require insurers to post online, which hospitals in their network have in-network pathologists, radiologists, emergency medicine doctors and anesthesiologists. Health plans that claim a hospital is in-network would get a green checkmark for each in-network specialty (of those four). A health plan with four checkmarks means that the in-network hospital has in-network physicians in each of those four specialties.

The CAP and the GAP strongly supported state efforts to hold health insurance plans accountable for contracting with in-network hospital-based physicians, the CAP noted in a January 28 letter to Rep. Mark Newton, MD, the bill’s sponsor.

“Insurance plans that represent to consumers that hospitals and facilities are ‘in-network’ when the plans have failed to contract with essential physician specialists at such facilities are providing fundamentally misleading information,” wrote CAP President Patrick Godbey, MD, FCAP. “House Bill 789 will help hold insurance plans accountable and transparent in this regard; we thus commend the bill and urge its enactment as part of any comprehensive solution to the issue of out-of-network balance billing.”

The CAP has long advocated for state insurance regulators, state legislatures, and the federal government to adopt standards that ensure patients have timely access to in-network hospital-based physician specialties at in-network facilities. If a health plan has inadequate in-network specialists, the CAP would like the plan to be responsible under law for paying out-of-network physicians the reasonable and customary rates for out-of-network services and at no greater out-of-pocket expense to the patient as would be the case for an in-network physician service.

Newton has said publicly that his measure is just a start to address surprise billing. The one lawmaker to cast a dissenting vote, Rep. Spencer Frye, said he actually supports the measure but doesn’t think it goes far enough.

The CAP will continue to provide updates on this important piece of legislation.

The CAP strives to reduce the Medicare reporting burdens placed on pathologists by providing the necessary resources to help members navigate the Merit-based Incentive Payment System (MIPS), including an updated list of applicable 2020 Improvement Activities for pathologists. Lock This is a member-only benefit.

The CAP has an ongoing engagement with CMS to identify pathology-specific guidance on 2020 Improvement Activities, which are available exclusively for CAP members.

Pathologists can perform or participate in different initiatives and projects to satisfy the same improvement activity. For 2020 reporting, pathology groups must retain documentation to show that 50% of the clinicians in the group (TIN) have performed or participated in an initiative or project to support the improvement activity or activities to receive credit.

Download Lock the CAP’s Guidance on Improvement Activities

Many activities that pathologists are already doing should qualify for improvement activities. The CAP’s 2020 recommended list of Improvement Activities Lock are organized in order of those activities most relevant to pathology practices.

The CAP has also produced a new case studies document Lock with a few examples showing how a group can satisfy some of the improvement activities requirements.

Email our experts with any additional questions about improvement activities or any other MIPS reporting question at

Members from the Florida Society of Pathologists will receive an exclusive update on federal and state advocacy programs on February 15 from CAP President Patrick Godbey, MD, FCAP.

Go to the Florida Society of Pathologists Annual Pathology Conference to learn more about its 46 Annual Meeting in Orlando, Florida, from February 14 through the 16.

To strengthen the profession of pathology at the local level, the CAP supports state pathology societies to bolster advocacy efforts on issues such as private insurance, billing, and scope of practice. The CAP’s leaders also directly speak and visit with pathologists at several state pathology society meetings throughout the year.

Dr. Godbey’s presentation will review the CAP’s advocacy efforts to enact federal surprise billing legislation, protect the value of pathology services, and the upcoming Pathologists Leadership Summit, among other topics.

Check our state pathology societies webpage for more information about support the CAP provides to state societies.

Take the Advocacy News Quiz and see how you stack up against your fellow CAP members. Tray and share your results on social media. Take the February news quiz today.