Read the Latest Issue of STATLINE
June 12, 2018
In This Issue:
CAP Leads Support of Health Plan Network Adequacy with Multiple Patient Advocacy Groups
The CAP, supported by a number of other health care organizations and patient advocacy groups, is advocating to ensure health plan network adequacy for all patients.
In a single public policy declaration, the groups call for state and federal regulators to ensure patients have reasonable and timely access to in-network hospital-based physician specialties – such as pathologists, radiologists and hospitalists – at in-network facilities under any health plan, including qualified health plans approved by the state or federal government.
“Specifically, every state or federal standard to govern health insurance plan network adequacy should assess whether the health plan network includes physicians who specialize in pathology, radiology and hospitalists in sufficient numbers at any in-network facility or in-network hospital included in such plan so that patients enrolled in these plans have reasonable and timely access to these in-network physician specialists,” the groups say in the policy statement.
If a health plan is inadequate for physician specialist services in pathology, hospitalist care and radiology services, the plan should be responsible for paying OON physicians the reasonable and customary rates for OON services, the declaration said. Furthermore, patients should not incur out-of-pocket costs that are greater than what they would pay for an in-network physician service.
In addition to the CAP, the following organizations have signed on to the declaration: American College of Radiology, Society of Hospitalist Medicine, National Brain Tumor Society, Leukemia and Lymphoma Society, National Kidney Foundation, Congenital Adrenal hyperplasia Research, Education & Support (CARES) Foundation, Epilepsy Foundation, Bladder Cancer Advocacy Network, Breast Cancer Action, Ovarian Cancer Research Fund Alliance and Kidney Cancer Association. The CAP expects that other medical organizations and groups will endorse the document over time.
The CAP has long advocated for network adequacy. The American Medical Association (AMA) public policy also supports network adequacy for an array of hospital based physician services. Accordingly, the CAP is working to ensure that all patients have reasonable and timely access to pathology services, along with other specialty services. This year, with state medical society support, legislation to require network adequacy for hospital-based physician services was introduced in Washington State, New Hampshire and Tennessee. The New Hampshire bill has passed the legislature and will be sent to the state’s governor.
NJ Governor Signs Balance Billing Measure into Law despite Opposition to Prohibition on Patient Waivers
New Jersey Governor Phil Murphy signed into law on June 1 a measure to prohibit balance billing of patients at in-network facilities. Notably, the new law includes a provision opposed by the CAP and the New Jersey Society of Pathologists (NJSP) that prohibits waiver of patient charges in all circumstances.
“The Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act” was passed by the state Legislature April 12 and becomes effective September 1. The law applies to emergency and “inadvertent” care provided by out-of-network (OON) physicians. In general, the provisions of the law are applicable only to state-regulated insurance plans, not federally regulated self-funded plans.
Not only does the law codify the state regulation that prohibits balance billing beyond a patient’s in-network rate, it also requires insurers to share network adequacy audits with the state. The CAP, the NJSP, and the New Jersey Access to Care Coalition lobbied vigorously for this provision, noting that network adequacy issues are still a problem and that transparency will help shed light on contracting issues and improve access for patients.
The CAP, NJSP, and the coalition also fought hard to find balance in the arbitration system. The new system uses “baseball style” arbitration (ie, the arbitrator must choose between the physician’s charge and the insurer’s offer of payment) when the difference between the charge and the offer is greater than $1,000. There are no caps on payments. Currently, New Jersey’s arbitration program uses Fair Health as a benchmark.
Of concern to the CAP and NJSP is a provision prohibiting waiver of copays or other patient liabilities. The CAP and the NJSP oppose this provision and had previously called for a conditional veto of the bill because of it. The NJSP states it will monitor enforcement to ensure that regulators do not apply that section of the law unfairly and that insurers do not use it to initiate or amplify frivolous fraud investigations.
The new law also places certain responsibilities on health care facilities and providers to notify patients about services they will provide and whether they are in-network or out-of-network.
The CAP and the NJSP will monitor enactment of the new law and seek appropriate legislative and regulatory remedies to outstanding issues.
Upcoming Webinar: Medicare Policy and Payment Changes for Pathologists: A look at what’s proposed for 2019
In the coming weeks, the Centers for Medicare & Medicaid Services (CMS) will issue its proposed updates to the 2019 Medicare Physician Fee Schedule and the Quality Payment Program regulations, including the Merit-based Incentive Payment System (MIPS) program.
Regulation changes will impact payment for services and pathologists’ participation in MIPS. Throughout this 60-minute panel discussion, CAP experts will review the proposed changes the fee schedule and MIPS. The webinar will begin at 1 PM ET on July 11. The CMS will finalize the 2019 Physician Fee Schedule and Quality Payment Program regulations during the fall of 2018. Presenters are:
Donald S. Karcher, MD, FCAP
Chair of the Council on Government and Professional Affairs
Emily E. Volk, MD, FCAP
Co-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