Advocacy Update

Read the Latest Issue of Advocacy Update

In This Issue:

The CAP, along with other physician specialties, applauded Reps. Raul Ruiz, MD (D-CA) and Phil Roe, MD (R-TN) for gaining 100 cosponsors for their bipartisan surprise medical bill legislation, the Protecting People from Surprise Medical Bills Act (HR 3502).

The legislation would ensure that patients have access to health care services and provide a fair process for resolving billing and payment disputes through an arbitration process based on a successful model used in New York state.

The CAP has encouraged the House Education and Labor and Ways and Means committees to consider this particular legislation as the most equitable and commonsense solution to financially protecting patients while tackling the surprise medical bills issue.

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The CAP, the American Medical Association (AMA), and 110 other physician organizations urged congressional leaders to refine surprise billing legislation that “represents a fair, market-based approach that treats all stakeholders equally while protecting patient access to care” in a recent letter.

In October 16 letters to respective leaders in the House and Senate, the groups said they remain committed to seeking a balanced legislative solution to protect patients from unanticipated medical bills. However, several legislative proposals favor insurers and may have unintended consequences for patient care.

“We are highly concerned that the rate-setting provisions in current bills further shift marketplace leverage to health insurers at the expense of providers,” the letter said. “As a consequence, this imbalance will likely lead to access problems for patients seeking hospital-based care from on-call specialists, as well as precipitate staffing shortages in rural areas and other underserved communities.”

The letters outlined elements of a balanced approach, which includes commercially reasonable payment for out-of-network services and an independent dispute resolution process designed to incentivize health insurers to make a fair initial offer of payment for out-of-network care provided to their customers.

Learn more about the CAP’s positions on surprise billing legislation.

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The American Clinical Laboratory Association (ACLA) filed a motion for summary judgment on October 14 in its case against the Department of Health and Human Services (HHS) and the flawed implementation of the Protecting Access to Medicare Act (PAMA). The motion for summary judgment asks the court to strike the HHS’ implementation of the law.

The initial lawsuit was filed by the ACLA and supported by the CAP through the filing of amicus briefs. In filing amicus briefs, the CAP has challenged how the HHS defined an applicable laboratory and the collection of laboratory data required by the PAMA law. By filtering out data from hospital laboratories and including data predominately from independent laboratories, the HHS all but ensured that laboratories would receive lower Medicare reimbursement for clinical laboratory tests, the brief stated. This is because independent laboratories generally receive lower rates due to economies of scale and purchasing power. Hospitals, on the other hand, serve inpatients and outpatients who have immediate needs during hospital visits, may offer around-the-clock services, and frequently provide the most complex clinical laboratory tests. “And that, in turn, will threaten the existence of certain laboratories, particularly in settings where costs are higher, including in rural markets, nursing facilities, and hospitals,” the CAP stated in the brief. Read the CAP’s full amicus brief.

The latest action followed a favorable decision by the US Court of Appeals that allowed ACLA, the CAP, and others to question the federal government’s PAMA administration.

The 2014 PAMA law drastically changed the Medicare clinical laboratory fee schedule (CLFS) by requiring reimbursements for clinical laboratory services to be based on private rates. The CAP has sought to ensure these reimbursements were accurate and reflect all sectors of the clinical laboratory market. However, the CAP found flaws in the private-market data collection process and has advocated for changes to the PAMA statute and resulting regulatory implementation.

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At a Michigan state legislative hearing on October 17, the Michigan Society of Pathologists (MSP), with support from the CAP, strongly opposed two bills that require out-of-network providers to offer patients notice that their services may not be covered.

The MSP and CAP opposed legislation that would limit physician payment to 150% of Medicare for out-of-network services. The MSP argued during the hearing that legislative proposals fail to address the underlying issue of health plan network adequacy. The CAP has long advocated for states to require health plans to have adequate networks of hospital-based physicians, including pathologists. The CAP has also supported the MSP’s advocacy efforts to lobby its legislatures.

The first bill, HB 4459 would add an article to the Michigan Public Health Code to limit the possibility of high charges when patients engage a doctor or hospital outside of their insurance network. Under certain circumstances, a non-participating provider would have to accept as payment in full the greater of the following:

  • The average amount negotiated by the patient’s health insurance with participating providers for the health care service provided; or
  • 150% of the amount that would be covered by Medicare for the service. The non-participating provider could not attempt to collect from the patient any amount other than the applicable coinsurance, copayment, or deductible.

The initial bill had established payment at 125% of Medicare, and was opposed by the CAP and MSP, as well as the Michigan State Medical Society. It is critically important that health care payment made by private insurance companies be reflective of the commercial market value of the service, the groups said. If such payments fall short, health plans would have no financial incentive to contract with physicians.

The second bill, HB 4460 would add that out-of-network providers must give patients a disclosure form with estimated charges in advance. 

James Richard, DO, FCAP, testified on behalf of the MSP and noted in its testimony that: “In pathology, the number of specimens taken during a procedure could be zero or could be dozens…The number or type of specimens subject to analysis cannot be reliably known or reliably predicted in advance of a procedure.” Furthermore, the he argued that: “....the estimate, when emanating from the physician, could diverge greatly from actual costs the patient would incur under his or her plan of insurance.” 

The CAP and MSP said the bills do not address the underlying issue of health plans failing to provide adequate access to in-network services for patients. Further legislative hearings on the legislation is expected.

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The CMS will soon publish updates to the 2020 Medicare Physician Fee Schedule and the Quality Payment Program regulations, which will affect payment for pathology services during the next year and beyond. On November 8 at 1 PM ET, the CAP will host a live webinar where CAP experts will review the final regulation changes that impact pay and pathologists’ participation in the Merit-based Incentive Payment System (MIPS).

Webinar presenters will be the Chair of the CAP Council on Government and Professional Affairs Jonathan Myles, MD, FCAP; Chair of the CAP Measures & Performance Assessment Subcommittee Diana Cardona, MD, FCAP; and Chair of the CAP Economic Affairs Committee W. Stephen Black-Schaffer MD, FCAP.

During the 60-minute webinar, the panel will also answer your questions on the fee schedule, MIPS, and other payment policies.

Register today for the webinar.

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Try your advocacy luck and take the October Advocacy News Quiz. See how your scores compare to your fellow CAP members and share on social media.

Over 100 of your fellow CAP members have already tested their advocacy knowledge for October. See how you stack up against your fellow pathologists on this month’s quiz and share your results. It’s easy, so good luck!

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