A path forward as Cigna ends PC clinical pathology payments

April 20, 2021

The following is a column from Vachette President Mick Raich:

Recently, Cigna announced it will no longer pay for the professional component of clinical pathology (PC/CP) beginning July 11. This comes as no surprise; we have seen this coming in recent years as UnitedHealthcare, Humana and Aetna have made similar moves. This trend is not going back. 

What will this change mean going forward? First, we have to consider the fact there are several states where Blue Cross still pays PC/CP. If your group is in one of these states, like Texas, you should be working on your revenue strategy going forward. Second, recognize there will be a time when Medicaid does not pay for these services going forward (Medicaid pays for PC/CP in several states.) Again, if you’re in one of these states you should build a revenue model that accounts for PC/CP payments being eliminated in the next five years.  

It is also time to review your current Cigna contract. Many of the older contracts have a direct payment tied to PC/CP. These contracts will need to be updated or non-payment may constitute a breach. If you can find your contract, it is imperative to review this document to make sure you have the correct terms going forward. 

Another available option is to notify the C-suite at your hospital. Informing them of this pay cut could create leverage you can use for future negotiations. Most importantly, if your Part A/Medical Director contract has a floor for contracted managed care relationships, you will need to raise that point as negotiations move forward. This is another reason why your hospital relationship is vital to a successful hospital-based pathology practice. 

So, what is your recourse? Primarily, you should negotiate a new Cigna contract. Calculate the losses from this change in PC/CP, add that number to your anatomic pathology fees and build this into your new projected fees. Remember to add a cost-of-living adjustment (COLA) increase to the contract. You need to create leverage so you can negotiate a favorable contract going forward.  You do not need to take a pay cut due to this change. With the correct leverage and data, you can actually negotiate a new better contract.

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