CAP, ASCP continue pushback against Anthem rate cuts

August 28, 2019

As Anthem continues to institute drastic fee schedule reductions for pathology services across several markets, they’re now receiving more unified resistance from pathology advocacy groups.

After Vachette first publicly broke the news of these cuts in April, both the College of American Pathologists and the American Society for Clinical Pathology have since joined the effort to seek a clear explanation from the payer as to how it justifies slashing major codes by as much as 80 percent from existing rates in some markets, including Missouri where these cuts first came to light.

In a July 16 letter to Anthem from CAP, they state, “On the information front, confusion continues surrounding the context, reasons and methodology for Anthem’s fee schedule changes.”

The letter goes on to say that Anthem reps indicated to CAP in May that the changes were intended rebalance rates across networks, regardless of setting. However, CAP then notes other members have heard different explanations, including that the changes may be tied to increases in Evaluation and Management codes, or that the new rates are meant to mirror those paid to large national labs, which CAP notes “would not be sustainable for smaller pathology practices.”

The ASCP, meanwhile more bluntly states that the new rates for many high-volume pathology and clinical lab services are “exceedingly low in comparison to Medicare’s payment amount.” The letter then goes on to list several extreme examples, including the reduction of 88305-26 from $66 to $14.43, which they note is nearly a third of Medicare’s rate of $39.64.

Fortunately, as we recently noted in a note to Vachette clients, Anthem has recently made a few concessions on its initial reductions as it has heard from an increasing number of unhappy providers.

In Missouri, Anthem issued revisions to their cuts for CPT codes 88300, 88302, 88304, 88305, 88307,88309, 88341, 88342. These revisions were implemented on Aug. 12, (with no reprocessing of claims paid under the previous fee schedule implemented 11/1/18). These codes were the only codes that were revised. All other codes (ie. professional interp, flow cytometry, touch prep, FISH) remain as cut 11/1/18 – significantly below Medicare.

We will continue to assist our clients and the larger pathology community in gathering and disseminating new information on this issue as it develops. In the meantime, please reach out to us if you have questions about whether your lab or group stands to be affected by these unprecedented changes.

Here is a brief rundown of when new fee schedules are set to go into effect across various state. Please not that many have already gone into effect.

MO – new fee schedule implemented 11/1/2018

AK – new fee schedule implemented 1/1/19

WA – new fee schedule implemented 1/1/19

CA – new fee schedule implemented 7/1/2019 (Prudent Buyer Plan)

NH – new fee schedule implemented 7/1/19

OH – new fee schedule set for 12/1/2019

IN – new fee schedule implemented 7/1/2019

GA – new fee schedule implemented 7/5/19

WI – new fee schedule implemented 8/1/2019

KY – new fee schedule set to roll out 9/1/2019 (note:  88300-88309 will not be impacted)

VA – new fee schedule set to roll out on 9/1/19

NY – new fee schedule effective 1/1/2020

Highmark WV – new fee schedule 9/1/2019

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