Read the Latest Issue of Advocacy Update
June 4, 2019
In This Issue:
- AMA Preview: CAP to Advocate for Network Adequacy, Pathology in Medical School
- Rep. Ruiz’s Proposal Creates a Fair Reimbursement System for Out-of-Network Patient Care
- CAP, ASP Secures Pathologists Ability to Perform Genetic Testing Without Written Consent
- New Colorado OON Law Drives Down Physician Payment
- Test Your Advocacy Knowledge - Take Our News Quiz
AMA Preview: CAP to Advocate for Network Adequacy, Pathology in Medical School
The CAP will lead a delegation of pathologists at the 2019 American Medical Association (AMA) annual meeting from June 8-12 in Chicago to set policy that affects the practice of medicine including, advancing appropriate “surprise” out-of-network policy, protecting payments for pathologists, and ensuring opportunities and educational resources for medical students interested in pursuing a career in pathology.
The CAP has a strong voice in the AMA’s House of Medicine. At the 2019 annual meeting, the CAP delegation will advocate for policies that protect patients from surprise medical bills and ensure network adequacy for pathologists, establish fair Medicare rates for pathologists, and identify potential education gaps regarding pathology and laboratory medicine in medical schools. Other issues that pathologists representing the CAP will engage on include:
- Federal health care reform proposals, such as Medicare for all Americans
- Augmented or artificial intelligence
- Direct to consumer diagnostic tests
The CAP is an active member of the AMA House of Delegates and encourages pathologists to join the AMA or renew their AMA membership. A robust CAP delegation at the AMA can shape a health care system that best utilizes pathologists to deliver high-quality care and meet the evolving demands of patient care. The CAP and AMA work together on many of the health and medical policies that affect the way you practice and your reimbursements. Join or renew your AMA membership today.
Rep. Ruiz’s Proposal Creates a Fair Reimbursement System for Out-of-Network Patient Care
In recent weeks, federal lawmakers from the House and Senate unveiled several legislative proposals to eliminate surprise medical bills. Rep. Raul Ruiz, MD (D-CA) proposed an outline for legislation that would hold patients financially harmless from surprise medical bills while creating a fair reimbursement system that keeps patients out of the middle of billing disputes.
Rep. Ruiz’s proposal aligns with the CAP’s principles to address surprise medical bills. In a statement, the CAP said: “The solutions as proposed would take necessary steps to accomplish our goals of holding patients financially harmless from surprise medical bills while creating a fair reimbursement system that keeps patients out of the middle of billing disputes. In particular, the CAP is pleased to see inclusion of a baseball-style arbitration process that allows consideration for a range of factors, including the usual and customary rate that reflects the market value of physician services.”
Pathologists have asked Congress to pass legislation that also requires network adequacy standards for health insurers. In addition to financial protections and fair reimbursement, network adequacy requirements are a necessary part of the holistic solution required to address the problem of surprise billing.
The CAP issued a statement on other proposals released in recent weeks. While all congressional proposals hold patients harmless from a surprise bill, none include network adequacy requirements. Narrow networks benefit insurers and allows insurance companies to shift the cost of care to the patient. Further, several congressional proposals mandate that providers be paid median in-network rates. If enacted, large insurance companies would gain the ability to set payment rates and eliminate the economic incentive for an insurer to negotiate a contract with a provider. As a result, insurers would be able to unilaterally determine the value of physician services and subsume the physician component of hospital care within its own financial, and, potentially, operational control.
The CAP has engaged and will continue to engage with congressional offices to address concerns of pathologists and their patients. Pathologists can also continue to urge their representatives and senators to pass reforms supported by the CAP by using the advocacy action center.
CAP, ASP Secures Pathologists Ability to Perform Genetic Testing Without Written Consent
On May 22, Arizona Gov. Doug Ducey signed into law legislation that permits a pathologist to order and perform genetic testing on a specimen without first receiving additional patient consent. For over three years, the CAP advocated to reduce regulatory burdens of genetic testing in Arizona. The change in statute was advocated for by the CAP and the Arizona Society of Pathologists (ASP), which argued that existing law posed “a substantial impediment to the practice of pathology for the benefit of patient care.”
In 2016, Arizona enacted a modified law that mistakenly encompassed in the definition of “genetic testing” tests that are fundamental to patient diagnosis and treatment for medical conditions such as cancer. That law stated that a genetic test could not be ordered or performed without the written informed consent of a patient for the ordering health care professional, including the receipt of the genetic test result. The change does not impact initial patient consent for taking and testing the specimen.
The overly broad definition in the original version of the law legally impeded a pathologist, who has no direct patient contact, and thus limited ability to secure patient informed consent in writing, from ordering the performance of a genetic test without legal jeopardy. According to the CAP and the ASP, these “genetic tests” are now the standard of care, to determine mutations that can now be targeted for certain therapies for personalized medicine. In light of current medical practices, Senate Bill 1297 removed these unintended legal impediments.
The new law allows a pathologist to order, perform, and receive the results of genetic tests for the patients, without legal impediment, in a manner that is consistent with the practice of medicine.
New Colorado OON Law Drives Down Physician Payment
The CAP had opposed a new Colorado law that will limit physician payment for out-of-network physician services at in-network facilities.
The new Colorado payment methodology for out-of-network physician services at in-network facilities limits physician payment to the greater of the 110% of the health plan’s median in-network rate, or the 60th percentile of the in-network rate as determined by the state’s all-payer claims database. If a physician holds the bill beyond 180 days, they will receive payment from the health plan at 125% of the Medicare rate for the service.
The legislation, which was signed into law by Gov. Jared Polis on May 14, bans balance billing of patients. The legislation had bipartisan support and overwhelmingly passed both houses of the Colorado legislature. The legislation was opposed by all physician groups, including CAP and the Colorado Society of Pathologists (CSP). The new act takes effect on January 1, 2020.
For years, the Colorado law ensured that patients were not required to pay more than their in-network rates for OON services at in-network facilities. However, the prior law did not ban balance billing, and health insurance carriers claimed that limiting payments to physicians was necessary to control health care costs. Some members of the Colorado legislature argued that physicians were overpaid, an argument supported by the director of the state’s Medicaid agency.
A CAP and CSP proposed an amendment to require the Colorado Department of Insurance to assess health plans for hospital-based physician network adequacy and to prohibit health plans from falsely claiming a hospital or facility was in-network when major physician specialties were not contracted for services. However, that amendment was defeated on the Senate Floor by a vote of 12-22.