Summary of the IssueHouse enrolled act HB 1004:
provides that for nonemergency services: "An out of network practitioner who provides health care services at an in network facility to a covered individual may not be reimbursed more for the health care services than allowed according to the rate or amount of compensation established by the covered individual's network plan" unless a written estimate is provided five days in advance of the service and patient written consent is obtained.Under this provision, a physician would be compelled to accept that insurer determined amount with:
1) no right of appeal to any independent mediation body; and 2) no statutory safeguard against being compelled to accept unreasonably low or de minimus payments that are far below Medicare rates.
The economic incentive on plans, through the OON payment formula in HB 1004, is to induce the termination of contracts with physicians and physician groups with adverse impact on all in-network contracts that are maintained as well. This thereby lead to cuts in health plan payments to in-network hospitals in the range of 12.5% to 25%.
For example, non-emergency surgical pathology may be unexpectedly needed as the result of an incidental tissue finding during a surgery. In routine screening procedures, pathology analysis may not be needed at all, or, alternatively may result in a single specimen or multiple specimens, with some that may require complex molecular/genetic analysis. Special staining of a pathology specimen is not known in advance and cannot be predicted. Quite simply, the written estimate section of the bill does not comport with the general practice of pathology.In sum, for these many reasons, HB 1004 overwhelmingly favors the insurance industry and presents for medicine one of the most draconian and detrimental out-of-network laws in the nation in terms of undermining the financial viability of nonemergency physician services in the hospital setting.
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Memo: Advocacy Fund
The Centers for Medicare and Medicaid Services’ (CMS) evaluation and management code (E/M) policy set to take effect on January 1. If Congress fails to act, pathologists will see an overall 9% cut to all pathology Medicare services to fund increases in payment for E/M services.
In the House of Representatives, a bill, H.R. 8702, was introduced by Representatives Bera (D-CA) and Bucshon (R-LA) to give physicians impacted by these cuts a hold harmless payment for two years (2021 and 2022). This will give us time to continue advocating for a longer-term fix. The bill currently has 53 co-sponsors. By following this link you are able to add your state pathology society’s name to the list of more than 300 national, regional, state and local organizations supporting the bill.
More information is available from CAP here