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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.

Cigna PC of CP Policy

On April 12, 2021, Cigna announced a payment policy change that would have denied all claims for the professional component (modifier 26) of clinical pathology (PC of CP). In a CAP letter to Cigna on April 23, 2021, the CAP urged the insurer to continue paying the PC of CP, stating that to discontinue reimbursement for these services would be detrimental to patients as well as to the integrated delivery of care, for which laboratory diagnostic services are essential. In response, Cigna revised its policy on the PC of CP, communicating to the CAP that it “will issue denials when the facility where the [PC of CP] services were provided is contractually responsible for laboratory management and oversight services.”

IMPORTANT UPDATE: The CAP followed up with an October 26 letter to Cigna seeking additional clarification of how pathologists should proceed under their revised policy. Cigna’s response to this letter explained that individual pathologists should submit claims for the PC of CP, and if “the facility … has already received payment for the service through their contract with Cigna,” they will be notified in the form of a denial through Cigna’s claim system. At that point, the pathologist should communicate with their facility (see pages 6-7 of the CAP’s PC Billing Information Package; login required) to determine whether payment for these services were in fact received from Cigna by the facility and, if the denial was made in error, then “this denial carries with it a right to appeal.”

See below for the CAP’s resources on Cigna and payment for the PC of CP. The CAP will continue to keep its members updated on the latest developments and offers resources to assist you in navigating the complexities of payer negotiations and contracting. And, read more practice management information.

Latest news on Cigna and payment for the PC of CP:

State Pathology Societies and the CAP Protect Pathologists' Payments

UnitedHealthcare Designated Diagnostic Provider

In early 2021, UnitedHealthcare announced a new benefit design where outpatient diagnostic laboratory services would only be covered for fully insured commercial plan members when delivered by a “Designated Diagnostic Provider.” The CAP met with UnitedHealthcare leaders to discuss the insurer’s upcoming plan changes and address a number of questions and concerns. In an April 20 letter, the CAP urged UnitedHealthcare to immediately and permanently cease implementation of this program because of the burden and confusion created for pathologists and their patients, the lack of transparency, and – most importantly – the potential financial harm for UnitedHealthcare plan members.

After CAP advocacy, UnitedHealthcare updated the program – currently, if a member has this benefit and receives services from a provider that is not a Designated Diagnostic Provider, services will be paid at the lowest tier/higher cost share according to their plan. The CAP is continuing to work on this issue and will update membership on any developments.

For more information, visit the UnitedHealthcare Designated Diagnostic Provider page.

UnitedHealthcare Test Registration

UPDATE: UnitedHealthcare is delaying the implementation of the clinical and pathology Laboratory Test Registry Protocol until further notice. This includes registration of non-genetic tests and placement of test codes on claims for non-genetic tests, there is no need to register non-genetic tests at this time.

UnitedHealthcare recently announced a new requirement for freestanding and outpatient hospital laboratories where these laboratories must register their unique test codes in advance and include this information on claims submitted to UnitedHealthcare.

The CAP is engaged on the new requirements, meeting with UnitedHealthcare on September 29, 2020 and sending a letter on August 26, 2020 to UnitedHealthcare’s leadership with its concerns. 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.

Read more:

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 with Cigna

      The CAP urges Cigna to pay for the professional component of clinical pathology services.

      Read our letter to Cigna Right Arrow
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