Read the Latest Issue of STATLINE

February 28, 2017

In This Issue:

Minnesota has joined a list of states that are taking action to address out-of-network billing by insurers, an issue on which the CAP has worked tirelessly. Out-of-network billing and network adequacy have increasingly become a concern as insurers continue to narrow their provider networks, making it difficult for patients to access in-network providers. Too often, patients don't even know if a provider they are seeing at a hospital is in-network, resulting in the patients receiving bills for out-of-network services.

The law signed by the Governor Mark Dayton on January 26 provides that patients will not be financially responsible for "non-authorized provider services" that occur when a patient receives services from a non-participating provider at a participating facility:

  1. due to the unavailability of a participating provider,
  2. without the patient's knowledge, or
  3. due to the need for unforeseen services.

In addition, the law provides that the patient will not be financially responsible for out-of-network costs when a participating provider sends a specimen to a non-participating laboratory, pathologist or other medical facility.

Specifically, the measure states: "An enrollee's financial responsibility for the unauthorized provider services shall be the same cost-sharing requirements, including co-payments, deductibles, coinsurance, coverage restrictions and coverage limitations, as those applicable to services received by the enrollee from a participating provider. A health plan company must apply any enrollee cost-sharing requirements, including co-payments, deductibles, and coinsurance, for unauthorized provider services to the enrollee’s annual out-of-pocket limit to the same extent payments to a participating provider would be applied."

The law also requires health plans to attempt to negotiate the reimbursement, less any applicable enrollee cost-sharing, for the unauthorized provider services with the nonparticipating provider. If the negotiation does not result in a resolution, the insurer or provider may refer the matter for binding arbitration. Of note, Minnesota establishes that arbitration consider payment based upon "the usual and customary rate for the service based on information available in a database in a national, independent, not-for-profit corporation."

The Commissioner of Health, along with the Commissioner of the Bureau of Mediation Services, must develop a list of professionals qualified in arbitration and publish it on the department's website. The new law takes effect 90 days after enactment. The new Minnesota law is similar to existing law in Illinois and in Florida governing out of network billing by facility based providers. Recently, the CAP and state pathology societies have urged states to consider similar legislation, including Washington State.

Back to the top

The Wyoming House of Representatives on February 14 adopted an amendment urged by the CAP that would ensure clinical laboratory diagnostic practices that entail genetic assessment of specimens are not inadvertently impeded by legislation designed to protect the privacy of genetic information "believed to predispose an individual to a disease, disorder, trait or syndrome, or to identify an individual or a blood relative."

The legislation (Senate File 31) would prohibit the collection, retention, and disclosure of genetic information without informed consent with some exceptions. The bill also authorizes an individual or the individual's authorized representative to inspect, correct and obtain genetic information and provides for the destruction of genetic information. The bill specifies criminal penalties for violations and provides for a civil right of action.

In a letter sent to Rep. Dan Kirkbride, chair of the Wyoming Joint Interim Judiciary Committee, the CAP argued that the bill should differentiate genetic testing for diagnosis and treatment from the predictive testing that is the subject of the bill’s protections and control. Without the inclusion of the amendment, the bill would have the unintended consequence of impeding standards of care in cancer diagnosis and treatment and other types of now standard medical practice activities, wrote Joe Saad, MD, FCAP, chair of the CAP’s Federal and State Affairs Committee.

The House agreed to adopt the following exception recommended by the CAP: "Diagnosis or treatment of the individual if performed by a clinical laboratory that has received a specimen referral from the individual’s treating physician or another clinical laboratory. Nothing in this paragraph shall be deemed to waive the requirement that a treating physician obtains specific informed consent for the taking of a specimen when required."

The Wyoming Senate voted its concurrence to the House amendment and the bill is now enrolled for the Governor Matt Mead's consideration.

Back to the top

The deadline is fast approaching for certain laboratories to submit private payor rates for clinical laboratory tests as required by the Protecting Access to Medicare Act (PAMA). Private payor data is due to the Centers for Medicare & Medicaid (CMS) by March 31, 2017, which is less than 33 days away.

To help you with the submission process, the CMS created a PAMA Data Collection User Guide with step-by-step instructions and screen shots.

The CAP has added this invaluable tool to our pathology-specific PAMA resources, including an informative infographic and podcast, to help laboratories understand regulatory requirements and upcoming deadlines. These resources and additional tools can be found on the CAP's PAMA resources webpage.

Back to the top

With a new presidential administration, the US government will pursue policies that are yet hard to predict. On February 21, 2017, the CAP presented A Seat at the Table—the Impact Only You Can Make on the Future of Pathology webinar. Attendees got first-hand accounts with down-in-the-trenches insight from presenters Joe Saad, MD, FCAP, the CAP's Federal and State Affairs Committee chair, and Michael Giuliani, the CAP's senior director of advocacy and former Hill staffer.

Watch the webinar.

Back to the top

On April 5, 2017, the CAP will present the Essential Tools for Pathologists Engaging in Grassroots Advocacy webinar that will provide a foundational training for members interested in becoming grassroots advocates. The 60-minute webinar will cover the basics of how Congress works, why grassroots matters and the tools and resources the CAP provides for members. We strongly encourage anyone attending the CAP Policy Meeting for the first time to participate, in order to gain a general understanding of grassroots advocacy before you arrive in Washington.

Whether you are DC bound or looking to get involved in your district, you'll want to hear from experienced advocates Joe Saad, MD, FCAP, Federal and State Affairs Committee Chair, Al Campbell, MD, FCAP, Grassroots Subcommittee Chair Federal and State Affairs Committee and moderator Michael Giuliani, CAP Advocacy Senior Director.

Register for the webinar.

Back to the top

With a theme of Protecting the Practice of Pathology and Our Patients, let your voice be heard at the 2017 CAP Policy Meeting. From April 24–26, CAP members can connect with government leaders and policy experts to discuss the impact of federal regulation on their pathology practices.

New regulations are taking shape that will impact pathology reimbursements for years to come. Beginning in 2017, metrics outlined by a new reimbursement system for Medicare take effect. Laboratories will soon have to comply with PAMA reporting rules.

At the 2017 CAP Policy Meeting, government leaders and policy experts will discuss how these major changes will impact your practice. You'll learn how to prepare your practice for these changes and how to make an impact on the regulations moving through Congress.

Back to the top