Advocacy Update

• CAP and Six Medical Organizations Call on UnitedHealthcare to Forego Designated Provider Program
• Support Sought to Address Social Determinants of Health, Close Medicaid Coverage Gap
• CAP Offers More Resources Pathology Consultation Services Codes
• HHS Releases More Than $2 Billion in Provider Relief Funds
• Washington State Pathologists Urge Strengthening of Network Adequacy Law
• 2022 Pathologists Leadership Summit Keynote Speaker Announcement
• Test Your Advocacy News Knowledge
• Breaking Advocacy News: Check out the Advocacy Twitter Channel

The CAP and six other medical professional organizations stated their concerns regarding UnitedHealthcare’s Designated Diagnostic Provider laboratory program in a letter on January 26. The groups urged UnitedHealthcare to update the program so it would not undermine the patient-physician relationship. The CAP engages with private-sector insurers, like UnitedHealthcare, to ensure access to pathology and laboratory services across all settings.

In a January 26 letter, the CAP, along with the American Medical Association, the American Academy of Dermatology, the American College of Obstetrics and Gynecology, the American College of Rheumatology, American Society of Dermatopathology, and the Medical Group Management Association asked UnitedHealthcare to seek stakeholder input from physicians and medical groups on the Designated Diagnostic Provider program.

The CAP has urged UnitedHealthcare to 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.

The CAP continues to work on this issue and will update the membership on any developments.

The CAP asked Congress to address social determents of health and close the Medicaid coverage gap in its next government funding bill. The CAP is committed to achieving health equity and addressing disparities in care to ensure quality, accessible patient care for all Americans.

In both letters to House and Senate leadership, the CAP said that expanding Medicaid coverage was essential to providing access to health care services. People without health insurance are more likely to delay needed medical care, including diagnostic testing and screening services. In addition, access to preventative care, cancer screening services, treatment for chronic illnesses, and mental health disorders are essential for communities of color, rural communities, and other underserved populations, the CAP said.

In 2021, the CAP also supported The Social Determinants Accelerator Act, which is still in the Senate for consideration. The legislation would address health determinants by providing grants for state, local, and tribal governments to develop strategies that target social determinants negatively impacting the United States’ most vulnerable populations. The legislation would also establish a federal interagency council to help grantees identify federal authorities, opportunities, and strategies to tackle these challenges.

To help our members understand the new CAP-developed pathology consultation service codes, the CAP published a new resource webpage for pathologists and their administrative staff as they implement them in 2022. The Centers for Medicare & Medicaid Services (CMS) finalized the CAP-developed pathology consultation services codes and values in the final 2022 Physician Fee Schedule. To help our members understand these new codes, the CAP developed a new resource web page for pathologists and their billing teams to navigate these new codes as they implement them in 2022 Medicare Physician Fee Schedule.

The Implementation Tips for CAP-Developed Pathology Consult Codes webpage includes an overview of the codes, the CPT descriptor, links to a webinar with case examples and scenarios of when to properly use these codes, frequently asked questions, and links to the American Medical Association’s (AMA) CPT resources.

The CAP worked with the AMA CPT Editorial Panel to establish pathology clinical consultation codes and develop new payment rates through the CAP’s role in the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The CMS accepted most of the CAP-developed relative values for the pathology clinical consultation services.

On January 24, the Department of Health and Human Services (HHS) released more than $2 billion for the Provider Relief Fund Phase 4 General Distribution payments to more than 7,600 providers nationwide. The CAP had encouraged pathologists to utilize the financial assistance from these federal programs if needed and has provided resources for this and other programs.

Additionally, the HHS has $6 billion left in the phase 4 provider relief distribution. The $2 billion in additional relief is the first distribution that falls out of the four reporting periods rolled out by the HHS in June 2021.

This portion is based on providers’ losses and expenses from July 1, 2020, through March 31, 2021, while relief recipients can use the funds to reimburse costs incurred from January 1, 2020, through at least December 31, 2022. The date that provider relief recipients received the Provider Relief Fund determines which spending deadline they must meet. Therefore, providers who received more than $10,000 in relief in the last reporting period, between July 1, 2021, and December 31, 2021, have to spend until December 31, 2022.

The Health Resources and Services Administration (HRSA) has information and reporting instructions.

Phase 4 payments focus on equity, including reimbursing a higher percentage of losses for smaller providers and incorporating “bonus” payments for providers who serve Medicaid, Children's Health Insurance Program (CHIP), and Medicare beneficiaries. Approximately 82% of all Phase 4 applications have now been processed.

On January 24, the Washington State Society of Pathologists (WSSP), with the support of the CAP, testified before the state House Health Care & Wellness Committee and urged passage of HB 1889 legislation that strengthens the state’s network adequacy requirements for health plans. In addition to the WSSP and the CAP, the bill is backed by the Washington State Medical Association and other physician specialties. The CAP advocates for states to require health plans to have adequate networks of hospital-based physicians, including pathologists.

Current state law, administered by the Office of the Insurance Commissioner (OIC), directs the agency to consider whether health plans have contracted with pathologists and other hospital-based physician specialists in determining whether the health plan meets minimum state regulatory standards. Those standards were enacted in 2019, largely as a result of the WSSP and the CAP’s advocacy over several prior years.

In submitted January 24 testimony before the Committee, the WSSP said that, “Washington is considered to have strong network adequacy laws and we’re grateful for the OIC's work in enforcing them. However, we believe that HB 1889 will necessarily give the OIC more tools to ensure network adequacy, and to keep pace with the increasingly aggressive tactics we’ve seen insurance carriers employ in contract negotiations (where we can get them to negotiate at all).” The legislation was opposed in Committee by the Association of Washington Health Care Plans. The CAP will continue to monitor during the legislative session.

The CAP is pleased to announce that the 19th director of the Centers for Disease Control and Prevention, and the ninth administrator of the Agency for Toxic Substances, is slated to speak during the Spring House of Delegates meeting at the Pathologists Leadership Summit.

Rochelle P. Walensky, MD, MPH, will be the keynote on Saturday, April 30 at the 2022 House of Delegates Spring Meeting—kicking off the Pathologists Leadership Summit. An influential scholar whose pioneering research has helped advance the national and global response to HIV/AIDS, Dr. Walensky is also a well-respected expert on the value of testing and treatment of deadly viruses.

As an exclusive member event, there is no fee to register for the Pathologists Leadership Summit.

Learn more and register

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