With letters dated April 1st, 2022, Cigna appears to be implementing an additional tactic to manage the carrier’s payment of the Professional Component of Clinical Pathology (PCCP). In the letter, Cigna has not indicated an intent to discontinue payment, but rather to cap the reimbursement at $5/test. To establish this policy Cigna indicates it took into consideration one or more of the following:
• Evidence-based medicine
• Professional society recommendations
• Centers for Medicare and Medicaid Services (CMS) guidance
• Industry standards
• Cigna’s existing policies
As a result of their review of the above factors, reimbursement will be capped for CPT® codes billed with a 26 modifier, when the professional/technical component (PC/TC) payment indicator is 3 or 9. These indicators can be found on the CMS Website, but include all clinical laboratory CPT codes. The new policy is slated to go into effect on July 1, 2022 according to the letter. This policy follows Cigna’s previous attempts to discontinue payment for PCCP as addressed in our previous white papers.
APS will continue to monitor this policy and advocacy against the change, which is certain to follow.
APS’ Last Correspondence on Cigna’s Efforts to Combat PCCP Payment
Several months ago, members of APS’ practice management team had the opportunity to join leadership within the Mississippi State Medical Association and our clients on a conference call with Cigna for further clarity on the carrier’s recent communication on its intent to discontinue payment of the professional component of clinical pathology (PCCP). Pathology groups across the country received these letters beginning in late September, which indicated a future effective date of this policy that is based off remittance and not date of service. Our call with Cigna answered some questions, but opened up others that were not satisfactorily answered.
One major point requiring clarity being sought was regarding the language on the letters indicating that the policy will go into effect:
“For pathology claims, we will issue denials when the facility where the services were provided is contractually responsible for laboratory management and oversight services.”
John Keats M.D., National Medical Director at Cigna was the primary speaker on Cigna’s end. He provided an overview of the new policy. According to Dr. Keats, Cigna’s contract language with hospitals has begun to include language indicating that the insurer is including payment for the pathologist’s oversight of the clinical laboratory for their patient population as part of the facility’s payment. This is a new program that Dr. Keats has seemed to pioneer. For pathology groups who service facilities with this language, Cigna intends to discontinue their direct payment of PCCP and expects the group to be reimbursed directly by the hospital.
The team on the pathologist’s side of the table went on to provide feedback that their partner hospitals are not aware of any increased payment and there is not a line itemization to their payment that indicates what, if any, portion is attributable to the pathologist’s oversight of the clinical laboratory. Dr. Keats indicated that he is unsure if this payment has a line item description to the hospitals.
It is important that our client base understands how this new program is being rolled out. Pathology groups with long standing contracts with Cigna, where the carrier has consistently paid PCCP as part of the contract, may now see that reimbursement disappear because Cigna has now promised their payment to the facility instead. We encourage you to work with the facilities you service to determine what their contract with Cigna indicates to determine if your reimbursement is at risk as this program continues to roll out. Working with your partner health systems to work out an understanding of this policy and its effect on your revenue is paramount. Further, groups should look to include future language within hospital contracts that allow for reevaluation of Part A reimbursement, when the hospital accepts a contract that shifts this revenue stream from the pathology group to the health system.
APS will continue to monitor this topic and provide any and all updates as they become available.
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