Read the Latest Issue of STATLINE
July 17, 2018
In This Issue:
- CMS Proposes Regulations That Will Impact Pathology Payment in 2019
- NH Balance Billing, Network Adequacy Law Takes Effect
- National Academies Report Details Process for Research Laboratories on Actionable Results
- CAP Helps Maximize Pathology Payments; Sign up for CAP 18 Sessions
- Upcoming Webinar: Medicare Policy and Payment Changes for Pathologists
- Decoding MIPS Webinar Series
CMS Proposes Regulations That Will Impact Pathology Payment in 2019
On July 12, the Centers for Medicare & Medicaid Services (CMS) released the proposed 2019 Medicare Physician Fee Schedule and the 2019 Quality Payment Program (QPP) proposals for Year 3 of the program. The CAP provided analysis of the regulations along with the proposed 2019 fee schedule impact table within hours of the regulations’ release last week.
Proposed 2019 Medicare Physician Fee Schedule
For 2019 payment changes to pathology services, the Medicare program proposed to accept several recommendations developed by the CAP and the AMA Specialty Society Relative Value Scale Update Committee for services provided by pathologists, such as CPT code fibrinolysins or coagulopathy screen, interpretation and report and some new fine needle aspiration services. In some instances, the recommendations reflect increases from current values for physician work.
Read more in the July 12 STATLINE alert.
CMS Proposes 2019 Medicare QPP Requirements
As is the case in 2018, nearly all pathologists will be required to participate in Medicare’s QPP either through Alternative Payment Models or the Merit-based Incentive Payment System (MIPS), according to the proposed regulation released July 12.
The CAP met with the CMS several times in 2018 to advocate for the CMS to reduce the burden of complying with MIPS, to ensure that pathologists can achieve full points, and make the program more flexible.
The CMS described Year 3 proposals for the QPP as historic, based on the administration’s regulatory relief initiatives. Read more in the July 12 STATLINE alert.
NH Balance Billing, Network Adequacy Law Takes Effect
A law prohibiting out-of-network balance billing and addressing network adequacy took effect on July 1 in New Hampshire. The legislation does not include an adverse payment methodology, but does include a new requirement on the Insurance Department to assess hospital-based physician network adequacy and authority to resolve payment disputes between payers and providers.
On May 10, the New Hampshire state house passed HB 1809 Legislature which was signed into law by Governor Sununu on July 2. The CAP, along with the New Hampshire Society of Pathologists (NHSP) and other physician and patient advocacy groups, advocated for network adequacy in the state for more than four years. Specifically, the legislation requires health plan network adequacy assessments by the Department of Insurance for hospital-based providers, such as pathologists, anesthesiologists, radiologists and emergency medicine physicians. In addition to securing network adequacy in New Hampshire, the CAP also was successful in including a mandate that the insurance commissioner provide an annual report on network adequacy to the appropriate legislative committees.
Strong support from the NH Medical Society and the NH Hospital Association helped the CAP and NHSP overcome initial resistance of the insurance commissioner in addressing network adequacy. The New Hampshire bill is an important milestone in the CAP’s advocacy efforts at the national level in support of network adequacy. The CAP has long advocated for health plan network adequacy for all patients. In fact, the CAP, supported by a number of other health care organization and patient advocacy groups, recently issued a single public policy declaration calling for state and federal regulators to ensure patients have reasonable and timely access to in-network hospital-based physician specialties at in-network facilities under any health plan. This year, with state medical society support, legislation to require network adequacy was introduced in Washington State, New Hampshire and Tennessee.
National Academies Report Details Process for Research Laboratories on Actionable Results
On July 10, the National Academies of Sciences, Engineering, and Medicine (NASEM) published the Returning Individual Research Results to Participants: Guidance for a New Research Paradigm report which established a process-oriented approach to allow research participants access to individual research results.
In September 2017, the CAP opposed the return of individual-specific research results to participants that are generated in research laboratories but do not have CLIA certification as the lack of CLIA certification raises reliability and accuracy concerns. Read the CAP’s 2017 comments to NASEM Committee.
Even though the final NASEM report states that research laboratories will not be mandated to use a CLIA certified laboratory, it does provide two pathways for laboratories to release results:
- For actionable results research laboratories should use CLIA laboratories to release those results, and;
- For non-actionable results, they will need to implement quality systems in order to release those results.
The report also outlines regulatory changes such as modifications to CLIA and Health Insurance Portability and Accountability Act that are needed in order to allow for the return of individual research results to the participant. The CAP recommended CLIA certification for research laboratories that wish to return of individual-specific research results generated in their research laboratories directly to participants. However, if a very significant finding occurred in a research laboratory that elects not to have CLIA certification, then the result should be confirmed in a CLIA certified laboratory.
In the study, which was sponsored by the CMS, the US Food and Drug Administration (FDA), and the National Institutes of Health (NIH), researchers sought to uncover paths toward delivering precision medicine by taking into account differences in lifestyle, environment, and biology. CLIA certification is required in order to perform testing on human specimens for the purpose of providing information for the diagnosis prevention, or treatment of any disease or impairment of, or the assessment of the health of human beings. However, research laboratories are excluded from these requirements.
CAP Helps Maximize Pathology Payments; Sign up for CAP 18 Sessions
Reserve your seat at featured Advocacy Courses
Registration is now open for vital CAP policy and advocacy courses and roundtable discussions that will impact the practice of pathology during CAP18 at the Hyatt Regency Chicago from October 20-24, 2018.
Learn about if you will be subject to a 4% penalty this year during the MACRAscopic Analysis of the New Quality Payment Program: Maximize Reimbursement While Demonstrating Value S1620 CME course at the annual meeting. On Monday, October 22 at 9:30 am, CAP experts will explain the MIPS reporting program and its implementation and provide current information on the ways you and your practice can successfully participate to avoid a penalty and potentially receive a bonus.
Additional CAP advocacy courses and roundtable discussions are also available at CAP18:
- STA008: How is My Payment Determined for Pathology Services? at 10:30 AM on October, 21
- R1690: My Surgical Pathology and Cytopathology Coding Dilemmas: Getting It Right—An Advanced Discussion at 12:00 PM on October, 21
- STA010: The CAP’s Policy and Advocacy Agenda on at 1:00 PM on October 22
- R1691: Current Payment Policy Challenges in Pathology Practice on October 23 at 12:00 PM
STA011: The Role of Pathologists in Population Health: An Interactive Discussion on October 23 at 12:30 PM
Check out the full list of Advocacy courses offered at CAP18.
Upcoming Webinar: Medicare Policy and Payment Changes for Pathologists
July 24, 2018
1 PM ET/ Noon CT
On July 24 at 1 PM ET, the CAP will offer a complimentary live webinar where CAP experts will review the proposed 2019 Medicare Physician Fee Schedule and the QPP regulations changes that will impact payment for services and pathologists’ participation in MIPS. The CMS will finalize the 2019 Physician Fee Schedule and Quality Payment Program regulations during the fall of 2018.
CAP webinar presenters are:
Donald S. Karcher, MD, FCAP
Chair of the Council on Government and Professional Affairs
Emily E. Volk, MD, FCAP
Vice-Chair of the Council on Government and Professional Affairs
Chair of the CAP Clinical Data Registry Ad-Hoc Committee
W. Stephen Black-Schaffer MD, FCAP
Chair of the CAP Economic Affairs Committee
Decoding MIPS Webinar Series
Navigating all the requirements related to successfully complying with MIPS can be confusing; especially for non-patient-facing physicians such as pathologists. And on top of that, you may be at risk for losing bonus opportunities if you don’t fully optimize your participation.
As part of our ongoing commitment to ensure pathologists are able to successfully participate in new and evolving payment models, the CAP is pleased to offer a comprehensive MIPS education webinar series specifically developed for pathologists, led by experts who will take a deep dive into components of the MIPS program. Upon completing the six webinars in this program, you will fully understand program requirements, be able to optimize your participation and successfully comply with MIPS.
The first in this webinar series – Maximize Your MIPS Bonus Potential – will take place on Thursday, August 9 at 12 PM ET/ 11 AM CT. During this 30-minute webinar, Diana Cardona, MD, FCAP, Chair of the Economic Affairs Measures & Performance Assessment Subcommittee, will review key elements of the MIPS program as it relates to understanding and maximize scoring, including selecting the right measures and improvement activities that have the maximum scoring and bonus point potential