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Private Sector Advocacy

Examining the State of Health Care's Private Payers and the Adverse Impact of Insurance Interference

The latest CAP report outlines how private health insurers are increasingly interfering in patient-physician and physician-physician relationships.

Read the Report Right Arrow

In its advocacy with private health insurance plans, the CAP champions policies protecting access to pathology services for patients, and protecting against overburdening pathologists with administrative requirements and interfering with the practice of medicine. Advocacy staff monitors developments at state and national levels – communicating updates to members while educating payers of any effect on the practice of pathology.

Note: The CAP offers resources to assist you in navigating the complexities of payer negotiations, contracting, and understanding the impact these contracts may have on your practice.

Change Healthcare Cyberattack

On Wednesday, February 21, 2024, Change Healthcare, which is owned by UnitedHealth Group (UHG), experienced a cyberattack that has had a significant impact on health care operations across the country. Pathologists have reported disruptions in claims processing, cash flow constraints, and other difficulties in day-to-day practice operations as a result. Below are the latest updates and resources to assist pathologists managing the fallout.

Resources:

News and other updates:

Optum Laboratory Benefit Management (LMB) Program

In a June 2, 2023 letter, the CAP expressed concerns with Optum's new LBM program and the negative impact it could have on patient care, including issues with (1) limits on the number of CPT 88305 units, (2) lack of transparency regarding the clinical guidelines being used by Optum or other details on how laboratory claims are evaluated, (3) evidence/guidelines utilized, appeals processes, and the qualification of administrators/reviewers, and (4) the requirement for specific Z-code identifiers on claims in order to receive payment.

UnitedHealthcare Z-Code Requirement

The CAP met with UnitedHealthcare representatives in August 2023 to discuss the proposed requirement that providers submit the appropriate Palmetto Z-Code for molecular diagnostic test services along with the assigned CPT code to be considered for reimbursement. While the CAP was successful in getting UnitedHealthcare to delay the requirement, in January 2024, UnitedHealthcare announced April 1, 2024 as the new effective date for the policy.

Read UnitedHealthcare's policy here and more from Palmetto GBA here. Providers who have questions or need assistance should email united_genetics@uhc.com.

Wellmark Blue Cross Blue Shield

On December 12, 2023, the CAP sent a letter to Wellmark expressing concern about policies that inappropriately limit physician decision-making in the provision of patient care, stating specifically that "the decision as to whether IHC is needed to make or to exclude a diagnosis in any specific case is complex, and dependent upon several factors including clinical history and presentation, patient demographics, anatomic location, and microscopic morphology." As a result, Wellmark announced they will rescind medical necessity reviews of IHC AMA-CPT codes 88341, 88342 and 88344 as outlined in Wellmark-EviCore Lab Management Guidelines, IHC Policy (MOL.CS.104.A, v2.0.2023). Prior adverse determinations processed under this IHC policy will be reprocessed retroactive to effective date October 1, 2023 and paid according to member benefits at date of service.

Anthem Healthkeepers

In October 2023, the CAP sent a letter to Anthem expressing concern with their restrictive requirements for laboratory referrals. The CAP wrote that hindering access to high-quality pathology services can negatively affect a patient's diagnosis, treatment, and outcome, and we requested an opportunity to discuss our concerns further.

Horizon BCBS New Jersey

On November 14, 2023, the CAP sent a letter to Horizon Blue Cross Blue Shield of New Jersey seeking clarification around an administrative policy update that changes how Horizon will “process certain claims submitted by hospital-based pathologists for services provided to members enrolled in plans/products that use the Horizon Managed Care Network.” The CAP emphasized concern with insurers’ restrictive reimbursement requirements and/or reliance on narrow/inadequate networks, which adds unnecessary burdens to receiving laboratory testing.

Highmark Credentialing Requirements

In 2022 and 2023, the CAP sent multiple letters to Blue Cross Blue Shield-affiliated Highmark about their new credentialing requirements for high-complexity laboratories. The CAP argued that this new requirement would not only fail to improve patient care but would distract laboratories from clinically relevant aspects of testing that could improve quality.

Cigna PC of CP Policy

On April 12, 2021, Cigna announced a payment policy change that would have denied all claims for the professional component (modifier 26) of clinical pathology (PC of CP). In a CAP letter to Cigna on April 23, 2021, the CAP urged the insurer to continue paying the PC of CP, stating that to discontinue reimbursement for these services would be detrimental to patients as well as to the integrated delivery of care, for which laboratory diagnostic services are essential. In response, Cigna revised its policy on the PC of CP, communicating to the CAP that it "will issue denials when the facility where the [PC of CP] services were provided is contractually responsible for laboratory management and oversight services." 

The CAP followed up with an October 26, 2021 letter to Cigna seeking additional clarification of how pathologists should proceed under their revised policy. Cigna's response to this letter explained that individual pathologists should submit claims for the PC of CP, and if "the facility … has already received payment for the service through their contract with Cigna," they will be notified in the form of a denial through Cigna’s claim system. At that point, the pathologist should communicate with their facility (see pages 6-7 of the CAP's PC Billing Information Package; login required) to determine whether payment for these services were in fact received from Cigna by the facility and, if the denial was made in error, then "this denial carries with it a right to appeal."

See below for the CAP's resources on Cigna and payment for the PC of CP. The CAP will continue to keep its members updated on the latest developments and offers resources to assist you in navigating the complexities of payer negotiations and contracting.

Latest news on Cigna and payment for the PC of CP:

UnitedHealthcare Designated Diagnostic Provider

In early 2021, UnitedHealthcare announced a new benefit design where outpatient diagnostic laboratory services would only be covered for fully insured commercial plan members when delivered by a "Designated Diagnostic Provider." The CAP met with UnitedHealthcare leaders to discuss the insurer's upcoming plan changes and address a number of questions and concerns. In an April 20, 2021 letter, the CAP urged UnitedHealthcare to immediately and 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.

After CAP advocacy, UnitedHealthcare updated the program – currently, if a member has this benefit and receives services from a provider that is not a Designated Diagnostic Provider, services will be paid at the lowest tier/higher cost share according to their plan. The CAP is continuing to work on this issue and will update membership on any developments.

For more information, visit the UnitedHealthcare Designated Diagnostic Provider page.

UnitedHealthcare Test Registration

As a result of CAP advocacy, UnitedHealthcare indefinitely delayed implementation of a previously announced requirement for freestanding and outpatient hospital laboratories where these laboratories would have needed to register their unique test codes in advance and include this information on claims submitted to UnitedHealthcare.

The CAP met with UnitedHealthcare on September 29, 2020 and sent a letter on August 26, 2020 to UnitedHealthcare's leadership with its concerns. The CAP argued that now is not the time to move forward with new requirements and potentially further disrupt revenues by denying claims for tests. Additionally, UnitedHealthcare's assertion that additional test information is needed does not warrant the added burden and stress of test registration, nor the deviation from consistent, uniform, national coding practice currently provided by the HIPAA-compliant and industry-standard CPT code set.

Anthem Fee Schedule Changes

Since April 2019, the CAP has engaged with Anthem Blue Cross and Blue Shield on policy regarding fee schedule changes to pathology services in several states. Given the serious impact on pathologists, CAP leaders pressed Anthem to reverse fee cuts to pathologists. The CAP has argued that the cuts undermine the viability of pathologists' practices and undermine access to care for pathology services, particularly in rural communities. More information can be obtained through our Advocacy Update publication and a July 2019 letter to Anthem expressing serious concern with the changes. The CAP sent a letter in September 2019 as a follow up to phone calls between CAP leadership and the insurer's leaders, and the CAP sent an additional letter in April 2020 stressing the serious jeopardy facing pathology practices today.

Impacted pathologists should contact their regional network manager for additional information; carefully review all contract amendments, communications, and other information; and/or consult local business advisors or attorneys for further advice. Pathologists may also want to contact their state pathology society or medical association for state-specific information or resources.

Read more:

Blue Cross North Carolina Billing Guidelines

The CAP asked Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to modify its proposed professional pathology billing guidelines, which is intended in part to inhibit the practice of "pass-through" or client billing. In a July 10 letter to the insurer, the CAP stated its support for Blue Cross NC's efforts to address pass-through billing, but the CAP also expressed concerns with the insurers' proposed billing guidelines that conflict with Medicare.

Horizon BCBS Limits to Pathology Services

The CAP opposed a new Horizon BlueCross BlueShield of New Jersey reimbursement policy that imposed limits on maximum daily units for surgical pathology and microscopic examination services. In a November 22 letter to Horizon BlueCross BlueShield of New Jersey, the CAP urged the insurer to reverse its restrictive policy and requested a meeting to discuss this issue further.

In January 2020, Horizon notified the CAP it would be revising the biopsy limits set forth in their policy.

Aetna Policy on Professional Component of Clinical Pathology

The CAP opposed a new Aetna reimbursement policy for pathologists in Texas and urged the insurer to continue payment for the professional component of clinical pathology ("PC of CP") services for all pathologists. In a December 20 letter to Aetna, the CAP explained that PC of CP services are critical to the reliable and accurate diagnosis and treatment of patients, particularly in delivery systems increasingly reliant upon care coordination, integration, and population management. The CAP stated that the Aetna policy of discontinuing payment for PC of CP services is not supported by CMS practices, and is disadvantageous to patients. The CAP has requested a meeting to discuss this issue further.

Laboratory Benefits Management Programs

To address laboratory benefit management (LBM) programs, the CAP established an advocacy position that supports legislation and regulation that appropriately limits the clinical role of LBM programs and other clinical decision support protocols. The CAP believes that governmental oversight and regulation of these programs is needed to (1) prevent conflict of interests by entities that administer these programs, and (2) to ensure these programs do not conflict with, subordinate, or unduly encumber the practice of medicine. Learn more about the CAP's policy for laboratory benefit management.

Prior Authorization

Prior authorization is a health plan cost-control process that requires providers to qualify for payment by obtaining approval before performing a service. The CAP agrees with the American Medical Association (AMA) and other stakeholders that this process is overused, costly, inefficient, opaque and responsible for patient care delays. In general, the CAP is concerned that utilization programs, prior authorization protocols, and other volume control methods that dictate or limit health care provider decision-making may impinge on the practice of medicine and could improperly encumber and curtail medically necessary clinical laboratory and pathology services. 

Read more: 

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Contracts-Negotiations and Fee Schedules

CAP resources to assist in navigating payer negotiations, contracting and understanding the impact these contracts on your practice.

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