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.
- CAP Policy - Pathologist Professional Component Billing for Clinical Pathology Services
- CAP PC Billing Information Package – Background and Guidance
- CAP Letter to Cigna, October 26, 2021
- CAP Letter to Cigna, April 23, 2021
Latest news on Cigna and payment for the PC of CP:
- Cigna Details Updated PC of CP Payment Policy; CAP Calls for Greater Clarification, October 26, 2021
- CAP Engages with State Pathology Presidents on Cigna’s Move to Deny Payment for PC of CP, October 12, 2021
- CAP Opposes Cigna’s Latest Plan to Deny Payment for PC of CP, October 5, 2021
- Cigna to Keep Paying the Professional Component of Clinical Pathology Services after CAP Expresses Concerns, June 8, 2021
- CAP Calls on Cigna to Rescind Policy to Deny Pay for Professional Component of Clinical Pathology, April 28, 2021
- CAP Opposes Cigna’s Plan to Deny Pay for Professional Component of Clinical Pathology, April 21, 2021
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.
- April 28, 2020: CAP Calls on Anthem to Stop Cuts to Pathologists
- August 29, 2019: CAP Leaders Press Anthem to Reverse Fee Cuts to Pathologists
- August 27, 2019: CAP is Urging Anthem to Reverse Policy Cutting Pay for Pathology Services
- July 23, 2019: CAP Urges Anthem to Offer Clarification on Changes to Pathology Services
- May 21, 2019: CAP Engaged with Anthem BCBS to Discuss Cuts to Pathology Services
- May 7, 2019: Anthem BCBS Revising Fee Schedules for Pathology Services in Several States
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 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.
- UnitedHealthcare Conveys Deadline Flexibility with Designated Provider Program, February 23, 2021
- UnitedHealthcare Delays Test Registry in Response to Concerns from CAP, November 3, 2020
- CAP Meets with UnitedHealthcare, Discusses Test Registry, October 6, 2020
- CAP Objects to UnitedHealthcare Test Registry Requirements, August 18, 2020
- CAP Secures Clarification on COVID-19 Test Prices from PA Insurance Department, August 18, 2020
- CAP Urges BCBS of NC to Align its Billing Policy with Medicare’s Rules, July 14, 2929
- CAP: UnitedHealthcare Should Stop Cuts to Pathologists, July 7, 2020
- CAP Objects to UnitedHealthcare Fee Schedule Cuts in Texas, June 30, 2020
- CAP Supports BCBS of North Carolina’s Efforts to Address the Practice of Pass-Through Billing, February 3, 2020
- NJ Pathologists Secure Revision on Insurer’s Limits to Pathology Services, February 3, 2020
- CAP Partners with Physician Associations Lobbying for a Balanced Solution on Surprise Bills, January 28, 2020
- CAP Urges Aetna to Reverse Reimbursement Limits, Clinical Pathology Services, January 14, 2020
- CAP Fights to Protect Value of Pathology Services in Year-End Legislation, December 17, 2019
- CAP Urges Horizon to Reverse New Limits on Units of Pathology Services, November 26, 2019
- CAP Members Push Lawmakers on Solution to Surprise Medical Bills, October 29, 2019
- 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