Advocacy Update

Read the Latest Issue of Advocacy Update

March 17, 2020

In This Issue:

Laboratory Inspections Suspended as a Result of CAP Advocacy

The COVID-19 pandemic is creating unique challenges for pathologists and our laboratories. In response, the CAP is working on multiple fronts to meet the needs of our members.

On Friday, President Trump declared a national emergency and, among other action, provided the Department of Health and Human Services (HHS) with broad authority to waive provisions of law and regulation to give physicians and hospitals “maximum flexibility to respond to the virus.” In an email to CAP members on March 16, CAP President Patrick Godbey, MD, FCAP, announced that following CAP Advocacy seeking relief from regulatory requirements, the Centers for Medicare & Medicaid Services (CMS) informed the CAP that it will suspend mandatory CLIA inspections for laboratories for a period of three weeks.

The CAP applauded this action by the CMS but also called on the agency to provide additional relaxation of certain CLIA requirements that the CAP and its members said unnecessarily impeded laboratory operations. Specifically, the CAP renewed its request for the CMS to grant a temporary waiver of CLIA rules requiring pathologists to be on site to read-out their cases in order to protect the laboratory workforce during this national health emergency.

Given the relaxation of federal telehealth restrictions on other health professionals, the CAP said it is critical that pathologists be given the discretion to work remotely. In addition, the CAP said that all laboratories should be given the discretion to determine what is best for their staffs to manage the pandemic. We must protect our personnel by deploying appropriate protocols to ensure we are not hindered in our ability to test and treat patients. At this crucial time a disruption in our workforce is counterproductive to our best interest and especially to the patients we serve.

Go to the CAP’s action center to contact HHS/CMS and your members of Congress to register your support today for the regulatory relief we are requesting. Please take a few minutes to respond to this action alert.

The CAP will issue more communications on what this change means to pathologists and their laboratories. These may not be the only issues that need to be addressed in the days ahead.

Coverage Update: AMA Establishes CPT Code for Coronavirus Tests, CMS Releases COVID-19 Coverage FAQs

The American Medical Association (AMA) fast-tracked a specific CPT code for COVID-19 laboratory testing. Also, the CMS released MAC test pricing and Frequently Asked Questions (FAQs) on Essential Health Benefits Coverage in response to the 2019 COVID-19 outbreak.

On March 13, the AMA announced a new CPT code for laboratories and providers to report COVID-19 testing for Medicare and private insurers. The new CPT code, 87635, will decrease regulatory burdens in the critical time of diagnostic testing.

The CPT Editorial Panel expedited the process, including the creation of a test description to accompany the code and the effective date of the code. The CPT Editorial Panel is an independent body convened by the AMA with the sole authority to manage revisions to the CPT code set. The AMA has worked to ensure the new CPT code meets the rising demands for accurate reporting of a COVID-19 diagnostic test. The CAP provided input to the CPT process prior to the Panel’s approval of the new code.

The CMS also recently announced two billing codes to be used by laboratories when testing for the virus Laboratories can bill HCPCS code U0001 for the CDC tests that diagnose SARS-CoV-2. The virus that causes coronavirus disease or COVID-19. The second HCPCS code U0002 allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2.

The CMS said Medicare claims processing systems would be able to accept these codes starting on April 1, 2020, for dates of service on or after February 4, 2020.

CMS Releases Test Pricing for COVID-19

On March 13, the CMS provided Medicare’s initial payment for the CDC test will be about $36 and a non-CDC tests will be around $51. These prices may vary slightly depending on the local Medicare Administrative Contractor (MAC).

Medicare will cover COVID-19 diagnostic tests, and there is no copay, however the Medicare deductible still applies. The CMS is also permitting Medicare Advantage plans to waive the cost-sharing for these tests.

CMS Releases COVID-19 Coverage FAQs

The CMS also released Medicare coverage FAQs that detail federal rules governing health coverage provided through the individual and small group insurance markets that apply to the diagnosis and treatment of COVID-19. The FAQs clarify which COVID-19 related services, including testing, isolation/quarantine, and vaccination, will be covered.

Additionally, the CMS updated their coverage FAQs for home health agencies for health care workers who are dealing with COVID-19 patients

Review updated guidance on COVID-19. For information specific to the CMS, please visit the Current Emergencies Website.

ONC and CMS Finalize Interoperability Rules, But Don’t Fully Address Information Blocking

The CMS and the Office of the National Coordinator for Health Information Technology (ONC) finalized interoperability regulations to revise how providers, including pathologists, will exchange health data. The CAP has urged the agencies to prevent information blocking by vendors and health care organizations so that data can be shared between electronic health systems while putting patient privacy at the forefront.

The regulations implement interoperability and patient access provisions outlined in the bipartisan 21st Century Cures Act of 2016. The regulations, released on March 9, would revamp how providers, insurers, and patients exchange health data to improve health care decision-making.

Previously, the CAP had cautioned the ONC against creating broad exceptions for vendors that would allow information blocking. However, the ONC maintained and added to the broad exceptions.

Health care providers, developers of certified health IT, and health information exchanges have six months after the ONC's rule is published in the Federal Register to comply with the information-blocking provisions.

The CAP will continue to provide updates to members on these new regulations.

WV Passes Historic Network Adequacy Bill After Years of WV Pathologists, CAP Advocacy

The West Virginia Legislature passed historic legislation that requires health insurance plans to guarantee network adequacy in the state, a move that the CAP has advocated for several years. The West Virginia Association of Pathologists and the CAP opposed out-of-network billing legislation because it failed to address the fundamental cause of balance billing – inadequate insurance networks.

The Health Benefit Plan Network and Adequacy Act (HB 4061), which passed on March 12, is largely modeled after the National Association of Insurance Commissioner (NAIC) model bill on network adequacy. The bill includes language that CAP secured in the NAIC model bill, with the CAP effectively leading the hospital-based physician coalition, requires health plans to report on “their process for monitoring access to physician specialist services in emergency room care, anesthesiology, radiology, hospitalist care, and pathology/laboratory services at their participating hospitals.” This standard has subsequently been adopted in multiple states, like Connecticut, Colorado, and Oregon, and also adopted by the federal government in the application process for federally qualified health plans in the federally facilitated insurance exchanges.

In addition, the bill requires health plans to have a process to assure that a covered person obtains a covered benefit at an in-network level of benefits, including an in-network level of cost-sharing, from a non-participating provider. The bill also requires the health plan to make other arrangements if the health plan has a sufficient network, but does not have a type of participating provider available to provide the covered benefit to the covered person.

Beginning January 1, 2021, health plans are required to submit to the insurance commissioner an access plan, which describes procedures for making and authorizing referrals within and outside it’s network, its processing for monitoring and assuring the sufficiency of the network, and the factors used by the plan to build its network.

The West Virginia Association of Pathologists and the CAP urged the Governor to sign the bill into law. In 2019, they opposed HB 2380, which defined a process for handling surprise bills. The same concerns were raised in 2017. The CAP has long advocated for states to require health plans to have adequate networks of hospital-based physicians, including pathologists. The CAP supports that any state-approved health insurance plan should include health plan network adequacy requirements.

Dr. Saleh: How You Can Champion Health Policy with PathPAC

Periodically, CAP Advocacy features one of the many CAP members who are champions for pathology through their advocacy at the federal or state level through our grassroots and PathPAC programs. If you would like to get involved, you can join PathNET, contribute to PathPAC, or join your state pathology society.

Recently Advocacy Update caught up with Jasmine Saleh, MD, who is a second-year pathology resident at Loyola University Medical Center in Maywood, IL. Even as a resident, Dr. Saleh has donated to the PathPAC as she understands how important it is to shape health policy for pathologists.

What drove you to get involved in advocacy?

My first Hill Day and meeting with policymakers, where we discussed the significant legislative issues facing our specialty inspired me to get involved in advocacy. The experience was rewarding and memorable as my fellow advocates and I educated congressional members on the vital role pathology plays in health care and patient care. Following this, my interest in advocacy led me to serve on my institution’s House Staff Quality and Safety Committee, and also the PathPAC Committee.

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

Once again, my favorite memory is attending my first CAP Policy Meeting and Hill Day. It provided a unique experience in advocacy that some residency programs may not be able to offer. It also enabled me to collaborate and network with other pathologists, residents, and legislative staff.

What advice would you give to your colleagues to be effective advocates?

There are numerous opportunities to get involved in advocacy. Join your institutional committees and state pathology societies. Participate in CAP residency forums and councils/committees. Attend activities sponsored by the CAP, such as Pathologists Leadership Summit and Hill Day.

Take the March Advocacy News Quiz

See how you compare against your fellow CAP members’ savvy advocacy knowledge. And then share your results on social media. Take the March news quiz today.