Advocacy Update

• Prior Authorizations Final Rule May Pave Way for Legislative Action
• CAP Opposes UnitedHealthcare Coding Policy Going into Effect April 1
• CAP Urges Pathologists to Respond to Reminders for AMA-Mathematica Physician Practice Expense Survey
• CAP Opposes State-Mandated Opioid Related CME Requirements
• Register for the Pathologists Leadership Summit in D.C. April 2024
• Take Our News Quiz for January

In September 2022, the House passed the Improving Seniors’ Timely Access to Care Act, a prior authorization bill to better serve patients and reduce unnecessary administrative burdens for clinicians. Since then, the Senate and House have been working with the Centers for Medicare and Medicaid Services (CMS) to advance the legislation to the President’s desk, but the bill’s cost has been a factor.

Following new regulatory changes to prior authorization rules by the CMS, the cost of the legislation is expected to decrease – which improves the chances of the bill one day becoming law.

The bipartisan legislation would:

• Establish an electronic prior authorization process that would streamline approvals and denials;
• Establish national standards for clinical documents that would reduce administrative burdens for health care providers and Medicare Advantage plans;
• Create a process for real-time decisions for certain items and services that are routinely approved;
• Increase transparency that would improve communication channels and utilization between Medicare Advantage plans, health care providers, and patients;
• Ensure appropriate care by encouraging Medicare Advantage plans to adopt policies that adhere to evidence-based guidelines
• Require beneficiary protections that would ensure the electronic prior authorization serves seniors first.

On January 18, the CMS released a final rule that makes important reforms in prior authorization programs for medical services. The rule is a direct result of important advocacy efforts taken by the CAP together with the American Medical Association and other physician organizations to address prior authorization in government-regulated health plans. As a result of the recent final rule, legislators now see a path forward toward enacting this legislation and making these reforms into law.

UnitedHealthcare has announced that its new Z-code requirement for certain genetic test claims will become effective on April 1, 2024. The Z-code requirement will initially cover 133 CPT codes and 104 proprietary laboratory analysis codes. Claims will be denied if the Z-code plus the appropriate CPT code information is missing.

UnitedHealthcare announced the Z-code requirement was going to be implemented in August 2023. However, the CAP met with UnitedHealthcare and was successful in getting them to delay this requirement until the new date, April 1. The CAP is currently working on scheduling a follow-up meeting with UnitedHealthcare leaders to get more information and continue to express our concerns.

The CAP opposes this requirement for specific Z-code identifiers on claims to receive payment, as it would be confusing and result in complex workflow processes that will be difficult for CAP members, especially those unfamiliar with Palmetto. Non-standard coding practices have serious negative consequences for pathologists and laboratories trying to implement conflicting requirements.

Additionally, the CAP supports the continued use of the CPT code set as it is developed with broad stakeholder input and provides a uniform language that accurately describes medical, surgical, and diagnostic services provided by physicians and other qualified healthcare professionals. The CAP believes that the CPT process would be the appropriate method for insurers to address any issues with information on specific tests and it would not add further requirements and reporting complexity for pathologists.

The CAP will continue to engage with UnitedHealthcare on this new requirement and will update membership on any developments. Read more.

Last week, Mathematica sent a reminder to nearly 10,000 physician practices representing 200,000 physicians regarding the AMA (American Medical Association) Physician Practice Expense Survey. The subject line of the email is “Reminder: The AMA needs your input to support fair and accurate physician payment.”

The CAP is one of more than 170 health care organizations supporting a national study by the AMA and Mathematica that will collect representative data on physician practice expenses. The aim of the AMA Physician Practice Information Survey is to better understand the costs faced by today’s physician practices to support physician payment advocacy.

Pathologists and their practices must watch for invitations to complete the survey. Invitations and reminders about the costs survey will come from PPISurvey@mathematica-mpr.com. Invitations and reminders about physician hours worked will come from PhysicianHoursSurvey@mathematica-mpr.com with the subject line: “Please help to update accurate physician payments.” Your input will ensure future pathology payment rates are accurate.

The study will serve as an opportunity to communicate accurate financial information to policymakers, including members of Congress and the Centers for Medicare & Medicaid Services (CMS). The survey will be administered through April 2024.

Physicians will be randomly selected to participate. If contacted, you will receive a $100 stipend for participating in the survey and your individual practice data will be kept private. Participation is voluntary but critical to the success of efforts to support accurate resource-based physician payment.

Again, the CAP strongly urges all physicians who are selected for the surveys to respond as soon as possible. For more information read the Physician Practice Information Survey Methodology Report.

The CAP has spoken out against state-mandated continuing medical education (CME) for opioid prescribing for physicians who do not have DEA (Drug Enforcement Administration) licenses. Quite a few states have applied the opioid CME mandate to pathologists and other physicians for whom this CME is of no medical value given the complete absence of prescription activity.

In a January 22 letter to the Federation of State Medical Boards (FSMB), CAP President Donald S. Karcher, MD, FCAP stated: “As a practical matter, while the CME is not overly onerous, it does detract from value-added medical education and medical practice time involving patient diagnosis and care. We further urge the FSMB to recommend to State Medical Boards, that are invested with policy or regulatory discretion, to exempt physicians under the pertinent CMEs’ categorical criteria to provide regulatory relief for physicians who can then devote such time to more useful medical activities germane to their scope of practice and further provide excellent patient care.”

The CAP will continue to engage with the FSMB on this matter to reduce unnecessary burdens for pathologists.

Year after year, pathologists’ Medicare payments are under threat, workforce shortages are causing burnout, and cuts to clinical laboratory payment hang in the balance.

Advocate for pathology and plan to attend the Pathologists Leadership Summit in-person where you will gain unparalleled access to the education and training to make an impact on Capitol Hill and protect the future of our specialty.

The Pathologists Leadership Summit takes place, in-person only, April 13-16 in Washington, DC. Mark your calendars and register today!

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