Private Health Plans

With the launch of laboratory benefits management programs and ongoing marketplace reforms, which includes network adequacy and addressing surprise billing, the role and effect of private payers will continue to rise. In addition, the growth in accountable care organizations and other alternative payment models in the private sector will also escalate at a rapid pace.

The CAP champions policies that protect access to care for patients without overburdening pathologists or interfering with the practice of medicine. Advocacy staff monitors developments at state and national levels – communicating updates to members while educating payers of any effect on pathology.

Laboratory Benefits Management Programs

To address laboratory benefit management (LBM) programs, the CAP established an advocacy position that supports legislation and regulation that appropriately limits the clinical role of LBM programs and other clinical decision support protocols. The CAP believes that governmental oversight and regulation of these programs is needed to (1) prevent conflict of interests by entities that administer these programs, and (2) to ensure these programs do not conflict with, subordinate, or unduly encumber the practice of medicine. Learn more about the CAP's policy for laboratory benefit management.

Prior Authorization

Prior authorization is a health plan cost-control process that requires providers to qualify for payment by obtaining approval before performing a service. The CAP agrees with the American Medical Association (AMA) and other stakeholders that this process is overused, costly, inefficient, opaque and responsible for patient care delays. In general, the CAP is concerned that utilization programs, prior authorization protocols, and other volume control methods that dictate or limit health care provider decision-making may impinge on the practice of medicine and could improperly encumber and curtail medically necessary clinical laboratory and pathology services.

Anthem Fee Schedule Changes

In early 2019, Anthem Blue Cross and Blue Shield announced it is rolling out fee schedule changes across a number of states. The CAP is aware of this issue and understands the serious impact on pathologists. We have engaged directly with Anthem to better understand the fee schedule changes and express our concern. According to the Anthem leadership handling this issue, the changes were an attempt to rebalance and better align rates across laboratory settings. The CAP recently sent a formal written response to Anthem expressing our continued concern.

Due to antitrust law, the CAP cannot be involved in fee schedule disputes. Thus, impacted pathologists should contact their regional network manager for additional information; carefully review all contract amendments, communications, and other information; and/or consult local business advisors or attorneys for further advice. Pathologists may also want to contact their state pathology society or medical association for state-specific information or resources.

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Read more on how CAP efforts promote favorable private payer coverage, payment, and other policies.

Related Resources

Our Position on Laboratory Benefit Management

We support legislation and regulation that appropriately restricts the clinical role of laboratory benefit management programs.

Read the full position statement Right Arrow