The College of American Pathologists (CAP) is urging Cigna to rescind a nationwide policy under which it would stop paying for the professional component (PC) of clinical pathology (CP) services beginning March 10. In a Jan. 10 letter to Cigna, CAP President Gene Herbek disagreed with Cigna’s position that the updated policy is consistent with Centers for Medicare and Medicaid Services (CMS) practices for billing the PC of CP services. CAP also underscored recent court decisions that have sided with pathologists in cases involving the PC of pathology services. “The PC of CP services under Cigna’s new policy for which reimbursement will be discontinued are services that are critical to the diagnosis and treatment of patients, particularly in a delivery system reliant upon increased coordination, integration, and population management,” said Herbek in the letter. According to CAP, Cigna asserted its decision to deny payment for the services during a routine policy review. As part of a larger claim-processing software implementation, Cigna will no longer pay claims submitted with modifier -26 when billed with laboratory and other codes. Cigna says this policy is consistent with CMS practices. CAP disputes that this change matches CMS guidelines. The college also noted that court […]
The College of American Pathologists (CAP) is urging Cigna to rescind a nationwide policy under which it would stop paying for the professional component (PC) of clinical pathology (CP) services beginning March 10.
In a Jan. 10 letter to Cigna, CAP President Gene Herbek disagreed with Cigna’s position that the updated policy is consistent with Centers for Medicare and Medicaid Services (CMS) practices for billing the PC of CP services. CAP also underscored recent court decisions that have sided with pathologists in cases involving the PC of pathology services.
“The PC of CP services under Cigna’s new policy for which reimbursement will be discontinued are services that are critical to the diagnosis and treatment of patients, particularly in a delivery system reliant upon increased coordination, integration, and population management,” said Herbek in the letter.
According to CAP, Cigna asserted its decision to deny payment for the services during a routine policy review. As part of a larger claim-processing software implementation, Cigna will no longer pay claims submitted with modifier -26 when billed with laboratory and other codes. Cigna says this policy is consistent with CMS practices.
CAP disputes that this change matches CMS guidelines. The college also noted that court rulings have made clear that pathologists through the PC of CP services provide “valuable and compensable medical services.” The 1995 federal case, Central States v. Pathology Laboratories of Arkansas, rejected an insurer’s argument that pathologists do not provide services to hospital patients.
“The court also underscored pathologists being present or on call 24 hours and intervening to ensure a test is done right, recheck a surprising result, or interpret ambiguous data in support of its ruling in their favor on payment for their PC of CP services,” Herbek noted in the letter.
Long-Running Dispute
There has been a long-running dispute over whether PC billing is a reasonable mechanism for compensating pathologists for their time and expertise in directing laboratories. Some patients and insurers object to such billing, arguing that it is inappropriate for a pathologist to bill a patient for a test if the pathologist has not personally performed the procedure or reviewed the results.
Pathologists have long billed private patients and private insurance companies for the PC of CP services. The American Medical Association, which develops and publishes all CPT codes, states that pathologists may bill for the PC of CP services using the -26 modifier.
Takeaway: Cigna’s decision to stop reimbursing the PC of clinical pathology services is at odds with long-standing policies and legal rulings.
