Read the Latest Issue of Advocacy Update
November 26, 2019
In This Issue:
CAP Urges Horizon to Reverse New Limits on Units of Pathology Services
The CAP opposed a new Horizon BlueCross BlueShield of New Jersey reimbursement policy that imposed limits on maximum daily units for surgical pathology and microscopic examination services. In a November 22 letter to Horizon BlueCross BlueShield of New Jersey, the CAP urged the insurer to reverse its restrictive policy and requested a meeting to discuss this issue further.
Specifically, the new policy would deny pathologists reimbursement for the same patient on the same date of service for the surgical pathology CPT code 88305. Horizon BlueCross BlueShield of New Jersey stated in its policy it would deny claims for 88305 services that are greater than 12 units for identified prostate diagnosis, greater than eight units for identified gastrointestinal diagnosis, and greater than four units for any other diagnosis not listed in the policy.
The CAP said the policy does not recognize the fact that pathologists and clinical laboratories do not control the number of specimens sent to them. “Horizon’s blanket policy improperly imposes limits on clinical physicians’ decision-making, impinging on the practice of medicine by inappropriately encumbering access to medically necessary pathology services,” the CAP said. “Any across-the-board limits should be set at a level likely to impinge only on rare and atypical practices, rather than limit necessary services typical in some of the many clinical settings in which tissue biopsy is called for.”
The CAP will provide updates in future newsletter articles.
CAP Expresses Practical Concerns With Price Transparency Regulation
The CAP and other hospital and medical groups oppose a price transparency regulation finalized by the Centers for Medicare & Medicaid Services (CMS) on November 15. The CAP had commented on the proposal in response to the 2020 hospital outpatient regulation, where the changes were originally proposed. The price transparency changes were then finalized in a separate regulation published on November 15.
Specifically, the price transparency final regulation requires hospitals to make public their standard charges for all items and services, including payer-specific negotiated charges. In its advocacy following the release of the proposed regulation, the CAP explained the significant difficulty in determining the cost of pathology services in advance of services conducted by the pathologist. The CAP opposed adding additional administrative requirements on physicians that interfere with or impair the patient’s medical diagnosis and care. Further, the CAP expressed that pricing data posted online by hospitals is often incomprehensible and unusable by patients, and may cause more confusion about the costs and quality of services.
In finalizing its regulation, the CMS acknowledged that disclosing price information would be burdensome for providers, but said, “the benefit of making the data publicly available outweighs that concern.” Hospital and medical groups, such as the Federation of American Hospitals, the American Hospital Association, the Association of American Medical Colleges, and the Children’s Hospital Association, said that forcing the disclosure of payer-specific negotiated prices requires hospitals to disclose trade secrets. The groups plan to file a lawsuit challenging the regulation.
Pathologists in California, New Hampshire Will Receive CAP Updates in December
Members from the California Society of Pathologists and New Hampshire Society of Pathologists will receive updates on federal and state advocacy programs next month. CAP President Patrick Godbey, MD, FCAP, will present at the California Society of Pathologists meeting on December 6 and CAP President-elect Emily E. Volk, MD, MBA, FCAP, will speak at the New Hampshire Society of Pathologists meeting on December 7.
At the California meeting, CAP staff also will be available to review Medicare’s Quality Payment Program and Merit-based Incentive Payment System (MIPS); and staff can further discuss the benefits for the CAP’s Pathologists Quality Registry as a MIPS reporting tool to meet Medicare requirements and improve quality.
To strengthen the profession of pathology at the local level, the CAP supports state pathology societies to bolster advocacy efforts on issues such as private insurance, billing, and scope of practice. The CAP’s leaders also directly speak and visit with pathologists at several state pathology society meetings throughout the year.
Dr. Godbey’s and Dr. Volk’s presentations will review the CAP’s advocacy efforts to enact federal surprise billing legislation, protect the value of pathology services, and the upcoming Pathologists Leadership Summit, among other topics.
Check our state pathology societies webpage for more information about support the CAP provides to state societies.