Read the Latest Issue of STATLINE
May 7, 2019
In This Issue:
- Pathologists Advocate to Protect Patients from Surprise Medical Bills; Urge PAMA Reform
- CMS Reopens NGS National Coverage Determination After CAP Concerns
- Anthem BCBS Revising Fee Schedules for Pathology Services in Several States
- CAP Notches Victory with North Dakota Bill on Out-of-State Pathology Consults
- 2019 Practice Characteristics Survey Is Open
Pathologists Advocate to Protect Patients from Surprise Medical Bills; PAMA Reform
CAP members made an impact on health policy by meeting with their federal legislators to advocate for patients and the pathology specialty on May 1 in Washington, DC. During the CAP’s annual Hill Day, more than 80 pathologists discussed how Congress could protect patients from surprise medical bills and improve how Medicare reimburses clinical laboratory tests.
About 160 meetings with congressional offices, pathologists advocated to amend the Protecting Access to Medicare Act of 2014 (PAMA) to reflect an accurate, market-based payment system for laboratories paid through the clinical laboratory fee schedule. CAP members also reviewed how the CAP can help protect patients from surprise medical billing disputes, ensure network adequacy, and if an out-of-network physician provides services to a patient, fairly compensate that physician for the services provided.
If you couldn’t make it to Washington this year, you can still make a difference from your home or office!
CMS Reopens NGS National Coverage Determination After CAP Expresses Concerns
After strong comments from the CAP, as well as several industry stakeholders, the Centers for Medicare & Medicaid Services (CMS) formally announced that it re-opened its national coverage determination (NCD) for next-generation sequencing (NGS) panels. The action followed stakeholder concerns regarding Medicare’s implementation of the NCD. The CAP had urged the CMS to change its NCD policy implementation on NGS for patients with advanced cancer.
The CMS is only reconsidering the evidence available for tests of germline mutations to identify those patients with hereditary cancer who may benefit from targeted treatments based on results of the test. All other tests are beyond the scope of this reconsideration. The CMS is interested in collecting feedback that includes scientific evidence and addresses the scope of this reconsideration.
In a January 28 letter to the CMS, the CAP, and other stakeholders asked the CMS to revise its current interpretation of the NCD by limiting it to somatic tumor testing and to communicate this change to the MACs. The letter was in response to the CMS’ interpretation that the NCD will apply to both somatic and germline NGS-based testing for late-stage cancers. The final NCD was widely interpreted by industry to apply only to somatic tumor testing.
The CMS has asked for comments by May 29. The CAP will continue to engage with the agency on this issue.
Anthem BCBS Revising Fee Schedules for Pathology Services in Several States
The CAP is aware of fee schedule changes being implemented by Anthem Blue Cross and Blue Shield that may result in reductions to pathology services.
The reimbursement policy affects, or will soon affect, Anthem’s commercial and Medicare Advantage insurance products in states such as Alaska, California, Indiana, Missouri, and Ohio. Pathology practices in these states have been receiving letters and other communications about the new fee schedule from the insurer. For example, a notification to physicians in Indiana is published online.
Anthem asks physicians with questions about the fee schedule change to contact their regional network manager for additional information.
CAP Notches Victory with North Dakota Bill on Out-of-State Pathology Consults
Because of one CAP member’s advocacy, North Dakota Gov. Doug Burgum signed into law legislation that effectively allows patients to receive second opinions from out-of-state pathologists and physicians without the requirement for state licensure. This marks the first legislative victory for the CAP in the state of North Dakota.
Mary Ann Sens, MD, PhD, FCAP, chair of the Department of Pathology at the University of North Dakota and a CAP State Issue Advisor, is credited with leading passage of the legislation on behalf of the CAP and pathologists across the country. CAP leaders cited Dr. Sens’ advocacy as an example of how just one pathologist can advance the practice of pathology in a state.
Prior to passage of SB 2094, consultations by out-of-state physicians had to be completed within 24 hours, which precluded any out-of-state pathologist second opinion on a pathology diagnosis. The measure, which sets new standards for telemedicine, extends the period for a one-time time consultation by an out-of-state physician on a diagnosis for a state resident from 24 hours to seven days.
The CAP has long held that a pathologist who engages in the interstate practice of pathology, including telepathology, and issues a diagnosis should have a full, unrestricted license to practice medicine from the state in which the patient presents for diagnosis, or where the specimen is taken or image is made. Of note, the CAP maintains that intra-specialty consultation from an out-of-state pathologist should not require in-state licensure provided that the consultation is at the request of an in-state pathologist licensed within the state.
2019 Practice Characteristics Survey Is Open
The CAP 2019 Practice Characteristics Survey is underway, and you can help by providing data from your pathology practice regarding your economic, demographic, and market trend information in the evolving business environment. The survey is open until May 17.
Respondents are eligible for a drawing for either one of three Amazon gift cards or Apple Watch® Series 4 wrist-wearable device. A winner was selected this week, but you can still take the survey and be eligible for a prize next week. Pathologists who respond to the survey will have early access to survey results via an exclusive webinar.
If you have not received your invitation, please contact us at firstname.lastname@example.org. This survey is available to board-certified pathologists who are currently practicing in the US. The survey excludes full-time retirees, pathologists practicing in different countries, and junior members of the CAP.
The survey should not take more than 15 minutes to complete. The CAP will share the survey findings with its members in a full report and provide early access to the data to those who finish the survey. If you have not received your invitation, you can take the survey.