Private Sector Advocacy

In its advocacy with private health insurance plans, the CAP champions policies protecting access to pathology services for patients, and protecting against overburdening pathologists with administrative requirements and 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 the practice of pathology.

Note: The CAP offers resources to assist you in navigating the complexities of payer negotiations, contracting, and understanding the impact these contracts may have on your practice. Click here for more information.

United Healthcare Test Registration

UnitedHealthcare has announced that effective January 1, 2021, claims for most laboratory test services must contain a laboratory’s unique test code for each service, and each test code submitted on a claim must match a corresponding laboratory test registration provided in advance to UnitedHealthcare. The insurer is recommending that free standing and outpatient hospital lab providers register their laboratory tests prior to December 1, 2020.

The CAP is engaged on the new reimbursement policy and on August 26, 2020, sent a letter to UnitedHealthcare’s leadership with its concerns. The various challenges the current pandemic presents to laboratories will likely continue through the beginning of 2021. Thus, the CAP argued that now is not the time to move forward with new requirements and potentially further disrupt revenues by denying claims for tests. Additionally, UnitedHealthcare’s assertion that additional test information is needed does not warrant the added burden and stress of test registration, nor the deviation from consistent, uniform, national coding practice currently provided by the HIPAA-compliant and industry-standard CPT code set.

Anthem Fee Schedule Changes

Since April 2019, the CAP has engaged with Anthem Blue Cross and Blue Shield on policy regarding fee schedule changes to pathology services in several states. Given the serious impact on pathologists, CAP leaders pressed Anthem to reverse fee cuts to pathologists. The CAP has argued that the cuts undermine the viability of pathologists’ practices and undermine access to care for pathology services, particularly in rural communities. More information can be obtained through our Advocacy Update publication and a July 2019 letter to Anthem expressing serious concern with the changes. The CAP sent a letter in September 2019 as a follow up to phone calls between CAP leadership and the insurer’s leaders, and the CAP sent an additional letter in April 2020 stressing the serious jeopardy facing pathology practices today.

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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Blue Cross North Carolina Billing Guidelines

The CAP asked Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to modify its proposed professional pathology billing guidelines, which is intended in part to inhibit the practice of “pass-through” or client billing. In a July 10 letter to the insurer, the CAP stated its support for Blue Cross NC’s efforts to address pass-through billing, but the CAP also expressed concerns with the insurers’ proposed billing guidelines that conflict with Medicare.

Horizon BCBS Limits to 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 from the CAP to Horizon BlueCross BlueShield of New Jersey, we urged the insurer to reverse its restrictive policy and requested a meeting to discuss this issue further.

In January 2020, Horizon notified the CAP it would be revising the biopsy limits set forth in their policy.

Aetna Policy on Professional Component of Clinical Pathology

The CAP opposed a new Aetna reimbursement policy for pathologists in Texas and urged the insurer to continue payment for the professional component of clinical pathology (“PC of CP”) services for all pathologists. In a December 20 letter to Aetna, the CAP explained that PC of CP services are critical to the reliable and accurate diagnosis and treatment of patients, particularly in delivery systems increasingly reliant upon care coordination, integration, and population management. The CAP stated that the Aetna policy of discontinuing payment for PC of CP services is not supported by CMS practices, and is disadvantageous to patients. The CAP has requested a meeting to discuss this issue further.

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.

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

Related Resources

Our Advocacy on Anthem Fee Cuts

The CAP’s leaders press the insurer to reverse decreases to pathologists.

Read the letter to Anthem Right Arrow