Advocacy Update

• HHS Releases Patient-Provider Dispute Resolution Guidance from No Surprises Act
• No Surprises Act Supersedes Adverse Indiana Out-Of-Network Law
• Registration Open for the 2022 Pathologists Leadership Summit
• Webinar: CAP Experts Provide Insights on Implementation of Pathology Consultation Codes
• Test Your Advocacy News Knowledge

On January 4, the Department of Health of Human Services (HHS) released the No Surprises Act Patient-Provider Dispute Resolution guidance, which helps providers understand what information to include for the good-faith estimates. The CAP worked closely with Congress during the development of the No Surprises Act and advocated for patient protections, but has continually expressed the serious risks for patient harm and substantial difficulty in determining the cost of pathology services in advance of services conducted by the pathologist.

While the No Surprises Act established an independent dispute resolution process for payment disputes between plans and providers, it also offers new dispute resolution opportunities for uninsured or self-pay individuals. This "Patient-Provider Dispute Resolution” process is available for uninsured or self-pay individuals who get a bill from a provider substantially in excess of the expected charges on the good-faith estimate (more than $400). The process uses a third-party arbitrator to review a patient’s good-faith estimate, final bill, and other information submitted by your provider or facility to determine a payment amount. Effective January 1, providers, facilities, and providers of air ambulance services will need to give an uninsured individual a good-faith estimate of expected charges after an item or service is scheduled or upon request. Important for pathology, from January 1, 2022, through December 31, 2022, the HHS will exercise its enforcement discretion in situations where a good-faith estimate provided to an uninsured (or self-pay) individual does not include expected charges from other providers and facilities that are involved in the individual’s care.

The HHS has related guidance for Providers and Facilities, Selected Dispute Resolution Entity, Uninsured or (Self-Pay) Individuals, and guidance on the Administrative Fee.

A 2020 Indiana out-of-network balance billing law, that was strongly opposed by the Indiana Society of Pathologists and the CAP, was deemed by the Centers for Medicare and Medicaid Services (CMS) as not meeting the standards established by the federal “No Surprises Act.” Accordingly, the No Surprises Act, which took effect on January 1, 2022, will supersede the Indiana out-of-network law.

The Indiana out-of-network law had allowed health insurance plans to unilaterally determine payment for non-emergency physicians for out-of-network services at in-network facilities at whatever amount was deemed “allowable” by the plan. In addition, there was no provision for physician appeal or arbitration provided under state law. A physician coalition effort, supported by CAP, urged the Indiana state legislature to repeal or replace the law, but the legislature deferred to the CMS decision.

In a December 15 letter to Indiana state officials from the CMS, the agency stated that it “understands that Indiana does not have an applicable All-Payer Model Agreement or specified state law that would determine the out-of-network rate. Therefore, the federal independent dispute resolution process … will apply for purposes of determining the out-of-network rate with respect to items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Indiana by nonparticipating providers, nonparticipating emergency facilities, or nonparticipating providers of air ambulance services.” The CMS further stated that it will enforce the outcome of the federal independent dispute resolution process for cases in Indiana.

Registration is now open for the CAP 2022 Pathologists Leadership Summit, April 30- May 3, 2022.

Receive the tools and training needed to build your leadership skills, and the opportunity to develop relationships with lawmakers, which is how our specialty can build our influence and make things happen in Washington, DC.

Begin your experience by helping to shape our specialty’s position on issues and network with leaders at the Spring House of Delegates Meeting, Saturday, April 30, which is being held in conjunction with the Pathologists Leadership Summit.

Enjoy access to experts, unparalleled education, and training throughout the Summit:

• Strengthen your ability to communicate, persuade, and lead with leadership-focused Education Courses, Sunday, May 1
• Gain the knowledge and skills necessary to be an effective advocate at our Federal Policy Agenda and Hill Day Preparation, Monday, May 2
• Meet with legislators in Congress and educate them on the health care issues impacting pathology at our Annual Hill Day, Tuesday, May 3

This meeting is a premier benefit of your CAP membership—there is no registration fee, and it includes free CME.

And, this year’s meeting will be held in a hybrid format, to allow for a healthy balance between your professional and personal needs. Let’s come together and make a positive impact for pathologists and patients.

There’s no time like the present to make a difference—and move pathology forward.

Register now

On Thursday, January 20 at 1 PM ET/ 12 PM CT, the CAP will offer a complementary 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

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