Read the Latest Issue of STATLINE

June 13, 2017

In This Issue:

The Pennsylvania Association of Pathologists (PAP) and the CAP are strongly urging state lawmakers not to pass legislation to prohibit balance billing of patients by out-of-network (OON) providers, arguing that the measure is flawed in a number of ways.

First and foremost, there is no evidence that balance billing is a significant policy issue of concern in Pennsylvania, say the associations, noting that the state Department of Insurance reports only 35 balance billing complaints out of 75,000 insurance complaints. Scenarios that create balance billing usually occur as the result of failure of insurers to ensure there are adequate in-network providers at hospitals and facilities that are in-network. The primary purpose of any proposed law to address OON billing should be the regulation of health plans to ensure that such plans provide the full continuum of in-network patient care, argue the PAP and the CAP.

"Specifically, in lieu of a ban on balance billing, the legislation should be limited to: 1. Network adequacy requirement that the Department of Insurance should enforce against health insurance plans to ensure that they contract with hospital-based physicians; and 2. The application of unfair trade practice penalties against health plans that deceptively market insurance products as having in-network hospital and facilities without providing medically necessary hospital-based specialties under contract,"" the groups write in a June 1 letter to Sen. Don White, chairman of the Banking and Insurance Committee.

The PAP and the CAP also note that the legislation's construction is flawed in several ways and that it fails to safe harbor physician waivers of OON charges. According to a recent national survey, approximately 22% of individuals who use OON providers negotiated an OON bill with the insurer or provider, and 58% were successful in reducing their costs for at least one of the bills. However, some insurers construe any physician waiver of co-payments, co-insurance, or deductibles on any patient claim as potentially fraudulent activity by the physician.

"Health insurance plans efforts to legally assail physician authority to waive charges, on a case-by-case basis, based upon a patient’s economics condition, creates a hostile legal atmosphere that is designed to deter such benevolent financial actions by physicians for their patients," the groups write. "Accordingly, physicians should have an explicit legal safe harbor in state law to conduct such waivers on out-of-network charges on a case-by-case basis so as to financially benefit economically distressed patients."

Finally, the groups argue that the legislation fails to recognize "usual and customary" charges used by insurers for OON payment. Both Aetna and United Healthcare, to some extent, use the 80th percentile of the Fair Health Inc. charge database for calculating OON payment. While these payors have fought against codification of this payment methodology, the PAP and the CAP believe their current use of this methodology reflects the suitability and appropriateness of this payment formula and that it should be included in the legislation as a parameter to be used by an arbitrator. In fact, they add, the state of New York in 2014 enacted this 80th percentile of charges formula for OON provider with no reported adverse impact on the health insurance market.

The CAP will continue to follow development of this legislation and will give updates in future issues of STATLINE.

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CMS Announces Alternative Payment Model Qualifying Participant Predictions

On June 2, the Centers for Medicare and Medicaid (CMS) released its predictions that nearly all of eligible physicians that participate in advanced alternative payment models (AAPMs) under the Medicare Access and CHIP Reauthorization Act or MACRA will be qualifying participants (QP) for the 2017 performance year. These QPs can receive up to a 5% AAPM incentive payment in 2019.

The MACRA final rule states that eligible clinicians become QPs for the 2017 performance year if they receive 25% of Medicare covered professional services, or see 20% of Medicare patients through an advanced AAPM.

Some of the ACOs that CAP members practice at may be an AAPM under MACRA, please check with your ACO to see if it is an AAPM. According to the 2016 CAP Practice Leadership Survey, about 30% of CAP members participate in one or more accountable care organizations (ACO).

The QP predictions CMS made were based on Medicare Part B claims with dates of service between January 1, 2016 and August 31, 2016 that were processed between January 1, 2016 and November 30, 2016.

Existing Medicare models that CMS indicated will initially qualify under MACRA as AAPMs are the Medicare Shared Savings Program model tracks 2 and 3, Next Generation Accountable Care Organization (ACO) model, Comprehensive ESRD model, Oncology Care Model (two-sided risk arrangements), and Comprehensive Primary Care Plus Model. Only the Next Generation ACO model and Medicare Shared Savings Program model tracks 2 and 3 apply to pathology.

For more information, please review this CMS Methodology fact sheet.

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Lisa Cohen, MD, FCAP

Lisa Cohen, MD, FCAP

STATLINE regularly features one of the many the CAP members who have been champions for pathology in Washington and at the state level through our grassroots and PAC programs. If you would like to get involved, you can join PathNET, contribute to PathPAC, or join your state pathology society.

Name: Lisa Cohen, MD, FCAP
Position: President & Chief Executive Officer, StrataDx, Lexington, MA

Why should your colleagues get involved in advocacy?

Pathologists who care about the future of our specialty should get involved in advocacy because we will only be effective in setting good policies and changing bad ones if we work together. It is power in numbers. If pathologists from all across the nation become engaged, we can affect the future of policy and reimbursement by working with our local representatives and senators. In the end, these policies affect patient care, and that is ultimately what matters. When elected officials make decisions without sound medical advice and scientific input, they could potentially implement policies that are out of sync with what is best for our patients.

Do you have a favorite memory or experience that stands out in your advocacy work?

My most memorable experience was meeting with Congressman Joe Kennedy during the Policy Meeting. He was personable, very interested, and compassionate in our cause, and let us take pictures with him. We were all a little star struck. The entire three days was also a great way to meet new people and share ideas with others around the country. It was my first Policy Meeting but won't be my last!

What was your greatest fear or concern about becoming an advocate for the profession before you got involved? Was your fear/concern justified?

My greatest fear before the meeting was not being prepared or knowledgeable enough about the topic. We had a full two days to learn everything we needed to know about the LCD issue before going to Capitol Hill to meet with our elected officials. The speakers were terrific, and I felt well prepared. Most of my meetings on Capitol Hill were with a group of pathologists as well, so there were a bunch of us to present and answer questions. It was a successful day, and we were well prepared for it.

It may be intimidating at first, but meeting with elected officials and their staffers is rewarding and fun. With a little training and a good understanding of the topic at hand, it is easy. You will always know more than the staffers, and they do appreciate your being there to advocate for your specialty. It's also a nice change from the medical side of what we do, and without advocacy from our own, there will not be anyone else to speak for us.

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In 2018, most pathologists will need to take action to stop penalties from reducing future Medicare payments for their services.

The CMS soon will issue its latest proposed rulemaking that implements provisions of the MACRA. On June 28 at 1:00 PM ET, the CAP will host a 60-minute webinar to discuss the CMS's proposals for participating in the 2018 Medicare Merit-based Incentive Payment System (MIPS) program, including options for preventing Medicare penalties.

Patrick E. Godbey, MD, FCAP, chair of the CAP's Council on Government and Professional Affairs; Jonathan L. Myles MD, FCAP, chair of the CAP's Economic Affairs Committee; and Diana M. Cardona, MD, FCAP, chair of the CAP's Economic Affairs Measures & Performance Assessment Subcommittee, will discuss how these proposed Medicare pay changes under MACRA will affect pathologists in 2018.

Register today.

By registering you will also receive a link to a recording of the presentation following the live event. Registrants will receive the link to the recording even if they are unable to attend the session on June 28.

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Mark your calendars as the 2018 CAP Policy Meeting is set from April 30 – May 2 at the Washington Marriott in Washington, DC. This is the meeting where CAP members can connect directly with government leaders and policy experts to discuss the impact of Federal regulation on their practice.

Registration will open soon for the CAP Annual Policy Meeting. Stay tuned for more updates.

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