Payment & Reimbursement Policy
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About Payment & Reimbursement Policy
Reimbursements made by insurers ultimately affect your pay, and the economic viability of your laboratory and business interests. The CAP has been intrinsically involved to ensure adequate representation for coverage and reimbursement issues facing pathologists in the legislative and regulatory landscape. We represent pathologists’ interests in nearly every payment-related policy discussion, including:
- The only pathologist organization on the American Medical Association (AMA) Relative Value Scale Update Committee (RUC), a committee that recommends what Medicare and most private insurers pay for physician services.
- Representatives on councils across the country that advise on local coverage determinations (LCDs) by insurers, so pathologists are appropriately reimbursed for medically reasonable and necessary services.
- Staff advocating on your behalf on the Medicare fee schedule via submission of formal comments and face-to-face meetings.
Producing Results that Matter
Through our advocacy to protect the value of pathology services, overall Medicare payments to pathologists have increased through the years. Due to the CAP’s engagement with the CMS and other stakeholders, our advocacy has achieved positive changes, resulting in increases in payment for pathology services between the proposed and final Medicare Physician Fee Schedule (PFS) rulemakings. Without the CAP’s advocacy on Medicare payment, it was estimated that reimbursements from Medicare to pathologists in the final rules would have been significantly lower.
What We Are Doing
Learn more about the ways we are fighting for fair pay for the value you provide as a pathologist:
Prevent Medicare Cuts for Pathology Services
The CAP has urged Congress to provide further economic assistance to pathology practices by directly engaging with congressional leaders with their concerns regarding the instability of Medicare’s payment system.
Medicare Physician Fee Schedule
Medicare's physician fee schedule information for pathologists that includes impact tables based on calendar year.
Medicare Coverage Advocacy
The College of American Pathologists Medicare Local Coverage Program reviews and comments on pathology-related local coverage determinations (LCD) and policy changes.
Private Sector Advocacy
The CAP strives to increase the visibility of pathology and educate private sector payers on pathology and promote favorable private payer coverage, payment, and other policies.
Surprise Medical Bills
Learn our policy recommendations aimed to relieve the anxiety patients experience from surprise medical bills.
Network Adequacy
CAP actively advocates for network adequacy of health plans by state regulators to ensure pathologists are participating providers in the plans.
Insurer Interference
In our latest report, Examining the State of Health Care’s Private Payers and the Adverse Impact of Insurance Interference, the CAP identifies four distinct but related categories illustrating how insurers interfere with physician services and patient care at the local level, including network manipulation and restricting patient care through prior authorization and other utilization management measures.
Alternative Payment Models
The CAP works to ensure pathologists’ role in coordinated care and alternative payment models, or APMS.
Value-Based Care
To ensure pathologists can participate and succeed in new value-based care models, the CAP has developed strategies to prepare pathologists for specific models utilized by public and private payers.
Digital Pathology Codes
As a result of CAP advocacy, digital pathology codes capture and report the clinical staff work, technical resources, and equipment required to digitize glass microscope slides for primary diagnosis.