Advocacy Update

• CAP Urges Congress to Stop Insurance Companies from Devaluing Pathology Services
• CMS Makes Technical Reporting Changes to CLIA Proficiency Testing Regulation for 2023
• Third Provider Relief Fund Reporting Period Now Open
• CMS Requires Health Plans to Discloses Service and Provider Pricing
• New Jersey Enacts Technical Fix Law to Address Pathologist Data Concerns
• Proposed 2023 Medicare Payment Regulations Webinar
• Test Your CAP Advocacy Knowledge
• Breaking Advocacy News: Check out the Advocacy Twitter Channel 

The CAP demanded that Congress take action to stop health insurance companies from devaluing pathology services. In its advocacy on private health sector issues, the CAP champions policies protecting the value of pathology and laboratory services.

In a July 14 letter to House Ways and Means Committee leadership, the CAP detailed how health insurance companies have, and continue to, devalue diagnostic pathology services. For example, the CAP stated that “with passage of federal legislation to address surprise billing, health insurance plans are increasingly relying on narrow and often inadequate networks of contracted physicians, hospitals, and other providers to shift medically necessary health care costs onto their enrollees.”

In addition, the CAP outlined difficulties with UnitedHealthcare’s Designated Diagnostic Provider program, where the CAP has urged UnitedHealthcare to immediately and permanently cease implementation of this program because of the burden and confusion it created for pathologists and their patients. “Even with recent modifications, the CAP believes UnitedHealthcare policies that subject patients to an increased payment for services received at in-network, but non-DDP facilities, is counter to efforts to protect patients and eliminate surprise medical bills,” the CAP stated in the letter.

The CAP also urged Congress to review how health insurance companies cut or stop reimbursements to critical patient services without any notification, creating a health care desert in rural and smaller pathology practices. The CAP will continue to advocate for pathologists to ensure fair reimbursement from private insurance companies.

On July 7, the Centers for Medicare & Medicaid Services (CMS) released the final 2023 Clinical Laboratory Improvement Amendments Proficiency Testing Regulations Related to Analytes and Acceptable Performance. This final regulation updates proficiency testing (PT) rules under the CLIA to amend the current list of regulated analytes to address newer technologies. The CMS added 29 analytes and removed five from its regulations. Download this fact sheet about the regulation from the CMS.

This final regulation also clarifies that waived testing is exempt from participating in PT regardless of if non-waived laboratories provide tests. However, if laboratories elect to participate in PT for waived testing, they are subject to PT referral and other requirements. The CAP advocated to ensure regulations balance patient safety without overburdening pathologists and laboratories.

The final regulation also revised the microbiology PT regulations to reflect current microbiology practices. The rule indicates that laboratories must report PT results for microbiology organism identification to the “highest” level on patient specimens to ensure that the “same” level is reported on patient specimens.

To accept general and/or targeted Provider Relief Fund (PRF) payments, physicians must complete reporting to the Health Services and Resources Administration (HRSA). For physicians who received more than $10,000 in the aggregate from January 1, 2021, to June 30, 2021, known as Reporting Period 3, the PRF Reporting Portal is now open and will remain open through September 30, 2022, at 11:59 PM ET. The CAP urges pathologists who must report to submit their information early and before the deadline.

New submitters should register in the PRF Reporting Portal. Pathologists who have previously reported do not need to register again and may log into the portal with their username, TIN, and password. Additional information on reporting may be found on the HRSA PRF website, which can be accessed on the PRF Reporting resources page.

The CMS announced that starting July 1, 2022, private, Medicare, Medicaid health insurance companies and self-insured employers must publicly disclose an itemized list of negotiated prices for health care services. The only excluded health services are the prices paid for prescription drugs, except those administered in hospitals or doctors’ offices.

The new rules are far broader than those that went into effect last year, requiring hospitals to post their negotiated rates for the public to see. Insurers must post the amounts paid for every in-network physician, hospital, surgery center, and nursing facility. In addition, insurers or self-insured employers could be fined as much as $100 a day for each violation for each affected enrollee if they fail to provide the data. Additionally, starting on January 1, 2023, regulations require insurers to offer online tools to help people get upfront cost estimates for about 500 so-called “shoppable” services, meaning medical care they can schedule ahead of time.

The New Jersey Society of Pathologists (NJSP) and CAP were pleased that the New Jersey Department of Health swiftly passed legislation (AB 4385) to address strong concerns raised by pathologists in March of this year. The legislation, recently signed into law by Gov. Phil Murphy, remedies the 2021 demographic data reporting law (Chapter 454), which had implications for locking out pathologists’ entry into laboratory information systems (LIS) where patient's gender and other demographic information were unavailable.

AB 4385 makes explicit that if certain demographic data is “not provided” to the laboratory for patient testing, the LIS system will not lock out pathologist or laboratory data entry or other known, pertinent information regarding the patient. Additionally, the bill adds a “not provided” option for pathologists and clinical laboratories to select when an ordering provider fails to obtain such information.

In March 2022, the NJSP raised operational concerns that the new data reporting law could impede the laboratory information system (LIS) use if not remedied or clarified. The CAP and the NJSP urged changes “to ensure that pathologist medical practice is not impaired by erroneous information technology implementation of any lockout feature that would deny supervising or diagnosing pathologists, and other laboratory personnel, the ability to enter known demographic information for patients in situations where other information regarding the patient is unavailable.”

As noted by NJSP President Valerie Fitzhugh, MD, FCAP, in her letter to the agency: “We do not believe that the law was constructed with the intent to block the medically appropriate data entry of known demographic patient information, but we want to preclude, in advance, such scenarios that would be erroneously premised upon a misconstrued application of the law.”

On Monday, August 8 at 1 PM ET/ 12 PM CT, the CAP will offer this complimentary live webinar where CAP experts will review proposed regulatory changes that will impact Medicare payment for services and pathologists’ participation in the quality initiatives. Join us for a deep dive into the proposed 2023 Medicare Physician Fee Schedule and the Quality Payment Program regulations, including the Merit-based Incentive Payment System (MIPS).

Webinar presenters will be the Council on Government and Professional Affairs Chair Jonathan Myles, MD, FCAP; Economic Affairs Committee Chair Stephen Black-Schaffer, MD, FCAP; and Quality and Clinical Data Registry Affairs Committee Chair Diana Cardona, MD, FCAP.

Register now

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