Opinion: Cigna PC/CP decision likely a temporary reprieve

July 1, 2021

The following is a column from Mick Raich, President of RCM Consulting for Lighthouse Lab Services:

As many in the pathology world know, the payment of the professional component of clinical pathology (PC/CP) has been evolving in recent years. Traditionally, this process involves a pathology group or laboratory billing for the PC of a clinical pathology CPT performed at a hospital. 

Over the years I have seen many changes in PC/CP compensation and have educated many hospital administrators on best practices for this process and the issues surrounding it. In the latest shift, Cigna noted in April that they would stop paying for these services beginning July 10. However, after significant industry pushback from The College of American Pathologists (CAP) and others, Cigna responded with a letter noting they would “reevaluate their approach” and “delay implementation” to allow time for further internal review before implementing this policy change.

So, what does this actually mean? Most likely, Cigna will slowly and by degrees stop paying for this service over time. I expect this gradual cutoff will not be as prominently announced as it was during this recent attempt. Labs and groups will instead learn of this change from their billers, or through an audit from Vachette. That’s why it will be imperative to monitor your PC/CP payments for the remainder of the year. 

This shift echoes what other payers have done during the past ten years in regards to PC/CP reimbursement. If you have a direct contract with Cigna, read it carefully. It will likely say they can change the payment for this service “from time to time,” leaving you vulnerable to their whims. So, what is the recourse to gain this revenue back? Your lab or group must consider renegotiating your anatomic payment rates to make up for this loss. The renegotiation takes time and leverage to complete, a process Vachette excels at.

Other items to consider:

  • Is your hospital contract up for re-negotiation? Can you add reimbursement for PC/CP in your Part A agreement?   
  • Consider locking in a “carve-out” agreement with Cigna that pays a flat rate per test, instead of being tied to the Cigna RVRBS? 

Need assistance navigating these renegotiations or projecting for these cuts? Reach out to us directly at 517-486-4262, or through our contact form.

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