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.
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 formal letter to Anthem expressing continued concern as a follow up to phone calls with the insurer’s leaders.
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.
Horizon BCBS Limits to Pathology Services
The CAP has 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.
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 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.
- Pathologists Oppose Pay Formula for Out-of-Network Services in Senate Bill, June 25, 2019
- CAP Asks HELP Committee to Set Fair Pay Mechanism for Surprise Bills, June 18, 2019
- CAP Engaged with Anthem BCBS to Discuss Cuts to Pathology Services, May 21, 2019
- Anthem BCBS Revising Fee Schedules for Pathology Services in Several States, May 7, 2019
- Insurance Network Participation Trends for Pathology Services, March 19, 2019
- Clash Over Technical Component Payments in Tennessee with BCBS Invokes Direct Billing Law Protections, October 31, 2017
- CAP Actively Opposing Expansion of BeaconLBS to Texas, March 14, 2017
- Voluntary Compliance for BeaconLBS to Begin in January for Texas Laboratories, November 15, 2016
- Humana Drops Policy to Deny TC Payment to Pathologists for Hospital Services, October 27, 2015
- Humana Policy Denies TC Payment to Pathologists for Hospital Pathology Service, September 22, 2015
- Large Insurers Anthem, Aetna Get Bigger Through Merger/Acquisition, July 28, 2015
- CAP Opposes UnitedHealthcare’s FL Program, April 14, 2015
- CAP Calls on UnitedHealthcare to Delay Beacon LBS, April 7, 2015
- Opposition Continues as UnitedHealthcare Moves to Fully Implement Beacon Pilot, March 10, 2015