Advocacy Update

• CAP, AMA Ask for APM Changes to Benefit Physicians
• CMS Updates Pathologists Payment Rates for 2022 After Congress Acts
• Data Reporting for Medicare Clinical Laboratory Fee Schedule Delayed until 2023
• Ohio Review Committee Develops Adverse Out-of-Network Rule Despite Pathology Concerns
• 2021 Webinar: CAP Experts Provide Pathology Consultation Codes Implementation Tips
• Last Chance to Test Your December Advocacy Knowledge
• Editor’s Note: Next CAP Advocacy Update is January 4

The CAP, the AMA, and a group of physician organizations urged the new director of the CMMI, Elizabeth Fowler, to make improvements in the development of alternative payment models (APMs). In the May 25 letter, the group made several recommendations to improve the process for designing and implementing APMs and engaging the physician community in their development.

The CAP, the AMA, along with 45 physician organizations, outlined the limitations of APMs, and how most physicians did “not have the opportunity to participate in an APM designed for the kinds of patients they treat or the level of risk they are equipped to take on. Existing models are also often geographically limited, excluding physicians in other areas who are interested and well-equipped to participate.” The group provided recommendations to the CMMI on improving APMs by:

• Increasing transparency and stability of APMs;
• Enabling APMs to reduce health inequities;
• Extending incentive payments for APM participation; and
• Investing in care transformation by medical practices.

The group also urged the CMMI to increase physician engagement in the development of future APMs by:

• Jointly setting joint goals and process;
• Dedicating funds to support development and testing of physician-developed APMs; and
• Providing feedback and data.

The group will follow-up with the CMMI on the future development of APMs.

The CAP updated its analysis of Medicare payment changes to pathologists for 2022 following congressional action to mitigate pay cuts earlier in December. Download our 2022 Medicare Physician Fee Schedule impact table showing these changes.

The Centers for Medicare & Medicaid Services (CMS) had published its final 2022 Medicare Physician Fee Schedule on November 2. The initial fee schedule included an overall cut of about 4%, which largely stemmed from Medicare policy to offset increases to evaluation and management services. The CAP lobbied Congress throughout 2021 to reduce the decreases in payment to pathologists and other physicians affected by the cuts.

On December 9, Congress responded by passing the Protecting Medicare and American Farmers from Sequester Cuts Act. The legislation increased payments on the Medicare Physician Fee Schedule in 2022 by 3%. The CMS followed by implementing the provisions in the law and increased the conversion factor used to calculate fee schedule rates to $34.6062 from $33.5983.

On December 10 the Protecting Medicare and American Farmers from Sequester Cuts Act delayed the clinical laboratory fee schedule private payor reporting requirement until 2023. The new CMS clinical laboratory fee schedule data reporting period will be January 1 – March 31, 2023 and will be based on the original data collection period, January 1 – June 30, 2019.

The law also extended the statutory phase-in of payment reductions, which meant there will be no payment reductions for services on the clinical laboratory fee schedule in 2021 or 2022, and payments won’t be reduced by more than 15% for 2023 through 2025.

Visit the PAMA Regulations webpage for more information.

On December 6, Ohio’s Joint Committee on Agency Rule Review (JCARR) declined to act on the Ohio Society of Pathologists (OSP) and the CAP’s concerns on the state’s adverse out-of-network rule (3901-8-17). The rule purportedly violates the legislative intent (HB 388) by applying the law’s applicability to all clinical laboratory services that are out-of-network. The CAP advocates for states to require health plans to have adequate networks of hospital-based physicians, including pathologists.

The OSP and the CAP argued the rule should be limited to out-of-network clinical laboratory services provided at in-network facilities. Additionally, the proposed rule’s requirement for written disclosure of out-of-network status prior to performance of clinical laboratory services was construed by the OSP and the CAP to not be contemplated in law. Both groups provided written and oral testimony also asserting the rule’s violation of JCARR’s criteria in which the proposal did not contain a complete and accurate rule summary in comparison to the rule’s Common Sense Initiative’s Business Impact Analysis.

Lori J. Elwood, MD, FCAP testified in opposition to the JCARR hearing to invalidate the rule due to the rule’s alleged violation of criteria in which the Department of Insurance (DOI) has or has not exceeded its statutory authority in the rulemaking process. Dr. Elwood said, “the Department of Insurance [has] instead proposed a rule that both transcends and violates Ohio's Out-of-Network law as it relates to clinical laboratory services. As such, this is the very scenario of rulemaking that JCARR was established to address and remedy.”

The OSP and the CAP were actively engaged in discussions with DOI and JCARR from the very beginning of the rulemaking process to rectify the apparent adverse impacts of the proposed rule. In November, both groups met with JCARR staff to express concerns on the proposed rule. Despite receptive discussions, the JCARR committee and the DOI decided to finalize the rule which will became effective on January 1, 2022.

On Thursday, January 20 at 1 PM ET/ 12 PM CT, the CAP will offer a complimentary live webinar where CAP experts will review implementation tips for the Pathology Consultation codes and answer questions. Webinar presenters will be the Council on Government and Professional Affairs Chair Jonathan Myles, MD, FCAP; and Economic Affairs Committee Vice-Chair Ronald McLawhon, MD, FCAP.

Register today

It’s the last week to test your December advocacy knowledge. See how you compare against your fellow CAP members in the December News Quiz and brag about your top scores on social!

Take the news quiz

Your Advocacy Update newsletter will take a scheduled break on December 28 and the next issue will be on January 4, 2022. For more immediate updates, please check out our Twitter feed @CAPDCAdvocacy.