Editorials
Once More Unto the Breach Timothy Craig Allen, MD, JD
‘‘D
uring a routine policy review,’’ Cigna (Bloomfield, Connecticut), a major medical insurer, announced that beginning March 10, 2014, it would no longer pay pathologists for the professional component of the clinical pathology services they provide, to wit, claims submitted with modifier 26 when billed with laboratory codes.1,2 The College of American Pathologists (CAP) responded in a January 10, 2014, letter that strongly challenged Cigna’s assertion that its decision was consistent with Centers for Medicare and Medicaid Services practices.1 The letter also highlighted the American Medical Association’s recognition of modifier 26 as appropriate to describe clinical pathology professional component services, and it emphasized the legal cases finding that pathologists ought to be able to bill for clinical pathology professional component services.1 After discussions with the CAP and others, Cigna has indicated that, while not withdrawing the payment policy, it would not proceed with the March 10 implementation date.3 But still, pathologists ask, What are they thinking? Payers have for decades made sporadic attempts to end clinical pathology professional component payment; Cigna’s new policy is one more try. The chaos surrounding the implementation of the Affordable Care Act, as well as recent Medicare cuts for pathology services, might suggest to payers that this is an opportune time for another attempt at that prize long denied. But Cigna should reconsider; its road to victory would be a long and difficult one. Arguments against denying pathologists payment for the work they do in the clinical laboratory—even if that work is frequently measured indirectly—are strong and convincing. Court decisions have almost consistently held that pathologists provide a valuable medical service in the clinical laboratory for which payment is due. And indeed courts should; most pathologists spend half of their residency years developing their clinical pathology skills. Some pathologists subspecialize, ultimately practicing entirely in the various realms of clinical pathology. Patients reap many tangible
benefits from the pathologists’ involvement in the clinical laboratory, including safe blood products, accurate blood tests, and timely microbiologic assessment, to name a few. Cigna’s new policy of nonpayment comes at a time of health care turmoil, but that turmoil should not translate into confusion, making this issue either overly consuming or overly discounted. The CAP engaged Cigna immediately upon Cigna’s announcement, and it will undoubtedly work closely with Cigna to come to a correct understanding. Pathologists, individually and through the CAP, are taking heed to ‘‘Stiffen the sinews, summon up the blood’’4 to prepare for a more proactive role in health care decision making needed to address this and numerous other local, state, and national issues that are likely to have an impact on pathologists’ patients as the Affordable Care Act becomes more fully implemented. Ultimately, this should evolve into an increasingly sophisticated, socially and politically involved society of pathologists who can more effectively act to protect and enhance patient safety and medical quality, both within the laboratory and beyond. References 1. CAP: Cigna should abandon plan to deny payment for clinical pathology services. Statline. January 16, 2014. http://www.cap.org/apps//cap.portal?_nfpb= true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_ windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D= statline%2Fstat011614.html&_state=maximized&_pageLabel=cntvwr# Story17BactionForm.contentReference%7D=statline%2Fstat011614.html&_ state=maximized&_pageLabel=cntvwr#Story1. Accessed January 21, 2014. 2. CAP opposes Cigna policy to deny payment for the PC of clinical pathology services. Statline. January 9, 2014. http://www.cap.org/apps/cap.portal?_ nfpb¼true&cntvwrPtlt_actionOverride¼%2Fportlets%2FcontentViewer% 2 F s h o w & _ w i n d o w L a b e l¼c n t v w r P t l t & c n t v w r P t l t %7 B a c t i o n Fo r m . contentReference%7D¼statline%2Fspecial_report_cigna_policy.html&_ state¼maximized&_pageLabel¼cntvwr. Accessed January 21, 2014. 3. Cigna Delays Professional Component of Clinical Pathology Policy. Statline. February 6, 2014. http://www.cap.org/apps//cap.portal?_nfpb=true&cntvwrPtlt_ actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel= cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=statline% 2Fspecial_report_cigna.html&_state=maximized&_pageLabel=cntvwr. Accessed February 18, 2014. 4. Shakespeare W. Henry V. Act 3.
Accepted for publication January 23, 2014. Published as an Early Online Release March 14, 2014. From the Department of Pathology, University of Texas Medical Branch. The author has no relevant financial interest in the products or companies described in this article. doi: 10.5858/arpa.2014-0043-ED Reprints: Timothy Craig Allen, MD, JD, Department of Pathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555 (e-mail: [email protected]). Arch Pathol Lab Med—Vol 138, June 2014
Editorial—Allen 727
Copyright of Archives of Pathology & Laboratory Medicine is the property of College of American Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Once More Unto the Breach Timothy Craig Allen, MD, JD
‘‘D
uring a routine policy review,’’ Cigna (Bloomfield, Connecticut), a major medical insurer, announced that beginning March 10, 2014, it would no longer pay pathologists for the professional component of the clinical pathology services they provide, to wit, claims submitted with modifier 26 when billed with laboratory codes.1,2 The College of American Pathologists (CAP) responded in a January 10, 2014, letter that strongly challenged Cigna’s assertion that its decision was consistent with Centers for Medicare and Medicaid Services practices.1 The letter also highlighted the American Medical Association’s recognition of modifier 26 as appropriate to describe clinical pathology professional component services, and it emphasized the legal cases finding that pathologists ought to be able to bill for clinical pathology professional component services.1 After discussions with the CAP and others, Cigna has indicated that, while not withdrawing the payment policy, it would not proceed with the March 10 implementation date.3 But still, pathologists ask, What are they thinking? Payers have for decades made sporadic attempts to end clinical pathology professional component payment; Cigna’s new policy is one more try. The chaos surrounding the implementation of the Affordable Care Act, as well as recent Medicare cuts for pathology services, might suggest to payers that this is an opportune time for another attempt at that prize long denied. But Cigna should reconsider; its road to victory would be a long and difficult one. Arguments against denying pathologists payment for the work they do in the clinical laboratory—even if that work is frequently measured indirectly—are strong and convincing. Court decisions have almost consistently held that pathologists provide a valuable medical service in the clinical laboratory for which payment is due. And indeed courts should; most pathologists spend half of their residency years developing their clinical pathology skills. Some pathologists subspecialize, ultimately practicing entirely in the various realms of clinical pathology. Patients reap many tangible
benefits from the pathologists’ involvement in the clinical laboratory, including safe blood products, accurate blood tests, and timely microbiologic assessment, to name a few. Cigna’s new policy of nonpayment comes at a time of health care turmoil, but that turmoil should not translate into confusion, making this issue either overly consuming or overly discounted. The CAP engaged Cigna immediately upon Cigna’s announcement, and it will undoubtedly work closely with Cigna to come to a correct understanding. Pathologists, individually and through the CAP, are taking heed to ‘‘Stiffen the sinews, summon up the blood’’4 to prepare for a more proactive role in health care decision making needed to address this and numerous other local, state, and national issues that are likely to have an impact on pathologists’ patients as the Affordable Care Act becomes more fully implemented. Ultimately, this should evolve into an increasingly sophisticated, socially and politically involved society of pathologists who can more effectively act to protect and enhance patient safety and medical quality, both within the laboratory and beyond. References 1. CAP: Cigna should abandon plan to deny payment for clinical pathology services. Statline. January 16, 2014. http://www.cap.org/apps//cap.portal?_nfpb= true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_ windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D= statline%2Fstat011614.html&_state=maximized&_pageLabel=cntvwr# Story17BactionForm.contentReference%7D=statline%2Fstat011614.html&_ state=maximized&_pageLabel=cntvwr#Story1. Accessed January 21, 2014. 2. CAP opposes Cigna policy to deny payment for the PC of clinical pathology services. Statline. January 9, 2014. http://www.cap.org/apps/cap.portal?_ nfpb¼true&cntvwrPtlt_actionOverride¼%2Fportlets%2FcontentViewer% 2 F s h o w & _ w i n d o w L a b e l¼c n t v w r P t l t & c n t v w r P t l t %7 B a c t i o n Fo r m . contentReference%7D¼statline%2Fspecial_report_cigna_policy.html&_ state¼maximized&_pageLabel¼cntvwr. Accessed January 21, 2014. 3. Cigna Delays Professional Component of Clinical Pathology Policy. Statline. February 6, 2014. http://www.cap.org/apps//cap.portal?_nfpb=true&cntvwrPtlt_ actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel= cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=statline% 2Fspecial_report_cigna.html&_state=maximized&_pageLabel=cntvwr. Accessed February 18, 2014. 4. Shakespeare W. Henry V. Act 3.
Accepted for publication January 23, 2014. Published as an Early Online Release March 14, 2014. From the Department of Pathology, University of Texas Medical Branch. The author has no relevant financial interest in the products or companies described in this article. doi: 10.5858/arpa.2014-0043-ED Reprints: Timothy Craig Allen, MD, JD, Department of Pathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555 (e-mail: [email protected]). Arch Pathol Lab Med—Vol 138, June 2014
Editorial—Allen 727
Copyright of Archives of Pathology & Laboratory Medicine is the property of College of American Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
