Advocacy Update

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In a September 13 response to the proposed 2020 Medicare Physician Fee Schedule (PFS) regulation, the CAP firmly stated concerns about proposals from the Centers for Medicare and Medicaid Services (CMS) to develop new bundled payments. The development of new bundled payments as proposed may violate Medicare statute, the CAP said.

The CAP urged the CMS not to develop bundled payments as there is not enough flexibility under the existing legal framework. The CAP asked the CMS to continue use of the existing Center for Medicare and Medicaid Innovation process for the development of voluntary models with physician input. The resource-based statutory requirement for physician services payment does not allow for the bundling the CMS describes in this proposed regulation, the CAP said.

In the same letter, the CAP emphasized its continued concerns around the physician self-referral, or the Stark law. The CAP expressed support for improving the Stark law advisory opinion process. However, the CAP asked the CMS to ensure that “any changes to the self-referral law do not further develop or create additional abusive self-referring arrangements that over-utilize services.” Moreover, as the CMS announced additional changes to the Stark law will be addressed in separate regulation, the CAP forcefully reminded the CMS to take action that closes the in-office ancillary services exception for anatomic pathology services.

The CAP will continue to work with the CMS to include the necessary changes in any efforts related to the bundled payments and self-referral law.

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New York state out-of-network law with an independent dispute resolution process has saved patients more than $400 million, according to a new state financial services report. The CAP has called the landmark state law a model piece of legislation and asked Congress to pass a similar federal law with an independent dispute resolution process soon. Moreover, the state law protects patients from emergency and surprise bills.

The law saved New York patients over $400 million, in part through a reduction in costs associated with emergency services and an increased incentive for network participation, from its March 2015 implementation through the end of 2018, according to the report.

The NYS OON law established an independent dispute resolution process for out-of-network emergency services, the law reduced out-of-network billing by 34% and lowered in-network emergency physician payments by 9%, according to the report.

The state law is similar to the provisions the CAP is asking from Congress in federal legislation, as outlined in the issue brief.

Specifically, the CAP asked Congress to pass federal legislation that does not compromise access to medical care and pass a similar federal law to the successful state law with an independent dispute resolution process soon.

Pathologists are urged to remain engaged with their elected officials in Congress on the surprise medical bill issue. CAP members can contact their senators and representatives on this important issue through our grassroots action network, PathNET.

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In response to concerns raised by the CAP and the Arizona Society of Pathologists (ASP), the Arizona Health Care Cost Containment System (AZHCCCS) amended its standards for assessing Medicaid managed care organization to address the need for adequate access to pathology and laboratory services. The CAP had requested that regulators require insurance companies to address the problem of network adequacy.

This positive response from Arizona follows almost a year of discussions between the AZHCCS, the CAP, the ASP, and the state organization representing health insurance plans. The discussions started as the result of the August 2018 correspondence from the CAP questioning the AZHCCS regarding its implementation of the federal law on Medicaid patient access and related standards, and the criteria for assessing network adequacy in its Medicaid MCO plans

In that 2018 correspondence, CAP noted, “This inquiry, in its entirety, is being made out of clinical concern that MCOs under contract with AHCCCS may be failing to contract with community and hospital based pathologists, especially in rural areas, and thereby failing to ensure that their enrollees have ‘adequate and timely’ access to medically necessary pathology services.”

Now, as the result of the agency favorable determination, beginning October 1, all Medicaid MCOs must submit a description of the contractor’s network for laboratory services, including pathologists available for physician referral, and how the contractor will assess the sufficiency of its network. This requirement applies to all Medicaid MCOs seeking approval for the 2020 plan year

The CAP will continue to advocate across the country for networks that provide adequate access to pathology and laboratory services.

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Try your advocacy luck and take the September Advocacy News Quiz.

Last month, over 200 of your fellow CAP members tested their advocacy knowledge. See how you measure up against your fellow pathologists on this month’s quiz and share your results. Good luck!

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