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UnitedHealthcare has notified the CAP that it will move ahead with fully implementing a laboratory benefit management pilot program in Florida despite objections from the College and pathologists in the state.

The CAP and Florida Society of Pathologists (FSP) are strongly opposed to the pilot, but remain engaged with UnitedHealthcare over the significant impact of the program on patients, pathologists, and ordering physicians.

UnitedHealthcare has communicated to its provider network that the insurer will implement "claims impact," or deny claims for laboratory services, under the pilot that requires use of the Beacon Laboratory Benefit System (BeaconLBS), a wholly owned subsidiary of LabCorp, in Florida. UnitedHealthcare will begin enforcement of the pilot on April 15, according to the announcement provided by the insurer to the CAP.

"That means program requirements must be followed or claims will not be paid for certain laboratory tests," UnitedHealthcare stated in the announcement.

The pilot program affects over 80 laboratory services ordered by a Florida network provider for a patient insured by most fully insured UnitedHealthcare commercial members in the state. UnitedHealthcare has revised its program so that for dermatopathology, cytopathology, and hematopathology, the insurer will accept either a single review from a subspecialist or a secondary review from an anatomic pathologist. Under standard practice, pathologists make decisions on a daily basis based on their professional judgment and training when to seek secondary reviews and who should provide them, based upon the patient's actual specimen, rather than as dictated by insurance company.

Before the initial intended full launch of the program in October 2014 and again at the end of 2014 before the revised full launch date of January 1, 2015, UnitedHealthcare had published notices about a decision to delay enforcement of the pilot program. A delay in claims denials had been in place since the initially intended October 1, 2014 effective date. Prior to that date, the CAP had several discussions with UnitedHealthcare and formally requested the insurer suspend its planned implementation of the pilot program.

The CAP has continued to engage with UnitedHealthcare expressing concern the program is fundamentally flawed and will negatively affect patient access to services, delay results, and create inconsistencies with current clinical practice, professional judgment and laboratory operations. For instance, the CAP strongly objects to the pilot's interference with medical judgment and new administrative burdens created by UnitedHealthcare.

The CAP, FSP, and several other physician organizations representing ordering physicians have objected to the program due to its clinical and operational implications. The CAP continues to advocate with UnitedHealthcare on behalf of pathologists and will continue to keep members advised of developments in STATLINE.

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The CAP and Michigan Society of Pathologists (MSP) successfully secured the recognition of pathology as a specialty subject to insurance network adequacy criteria for health plans in Michigan.

An acknowledgment of pathology had been absent in the state of Michigan Department of Insurance and Financial Services guideline for determining health insurance network adequacy. After discovering the omission, the CAP and MSP worked with the department to have pathology added. On October 21, 2014, MSP President Rouba Ali-Fehmi, MD, FCAP wrote the department a letter stating in-network adequacy criteria for pathology services is needed to ensure patient access to high quality medical care.

"Pathologists play an integral role in health care as physicians who obtain and interpret data as the result of examination of tissues, blood, and other body fluids for diagnosis and patient care," Dr. Ali-Fehmi said. "Pathologists provide interpretative services of pathology/laboratory specimens and reports for both clinicians and patients. Clinical laboratory testing drives 70% of medical decision-making. Furthermore, with the advent of genomic medicine, the role of the pathologist in patient care is even more crucial in the process to identify biomarkers for each patient's disease, especially in cases of cancer, that can help inform and guide the most appropriate treatment option."

On March 2, the CAP and MSP received confirmation from the state that pathology was added to network adequacy guidelines.

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The CAP, American Medical Association (AMA), and nearly 100 state and specialty societies urged the CMS to address several concerns about contingency plans to avert disruption to physician practices during the upcoming transition to the ICD-10 code set.

In a letter to Acting CMS Administrator Andrew Slavitt, the CAP and other organized medicine groups stated disruptions during the transition on October 1 could cause serious access to care issues for Medicare patients. Recent testing by CMS showed claims acceptance rates would drop to 81% from 97% if the health care system began using the new diagnosis code set today.

"By itself, the implementation of ICD-10 is a massive undertaking,"the letter stated. "The undersigned organizations remain gravely concerned that many aspects of this undertaking have not been fully assessed and that contingency plans may be inadequate if serious disruptions occur on or after October 1. Furthermore, physicians are being asked to assume this significant change at the same time they are being required to adopt new technology, re-engineer workflow, and reform the way they deliver care—all of which are challenging their ability to care for patients and make investments to improve quality."

The physician groups called on the CMS to also consider how the transition to ICD-10 will impact quality reporting programs such as the Physician Quality Reporting System (PQRS) and Meaningful Use (MU) of electronic health record systems. Because PQRS and MU quality reporting periods are based on the calendar year and the switch to ICD-10 will be occurring more than three quarters of the year in, the quality measures for 2015 will be reported and tabulated with both ICD-9 and ICD-10 codes.

"We are concerned the administration is underestimating the impact the transition to ICD-10 will have on the regulatory tsunami that is already burdening physicians and threatening access to quality care," said AMA President Robert M. Wah, MD. "Although we appreciate the training, educational tools and other efforts by CMS to prepare physicians for the ICD-10 transition, it is clear that more information is needed about how the shift will impact quality reporting so physicians can avoid penalties."

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Sign up today to register for the CAP’s March 31 webinar, Results from CAP's 2014 Practice Characteristics Survey.

The Practice Characteristics Survey is a primary source of basic data on the socioeconomic aspects of CAP member practices, and tracks and reports changes that are occurring in the practice of pathology among College members. In December, the 2014 Practice Characteristics Survey Report was published by the CAP Policy Roundtable, a subcommittee of the Council on Government and Professional Affairs.

This 60-minute presentation will review the survey findings and provide a forum for CAP members to ask questions about the report. The webinar, previously scheduled for February 26, is now March 31 at 2 PM ET and will feature Policy Roundtable Subcommittee Chair Michael B. Cohen, MD, FCAP; Policy Roundtable Survey Project Team Chair Thomas M. Wheeler, MD, FCAP; and Policy Roundtable Director David J. Gross, PhD.

Register today!

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