Aetna Cuts Pathology Reimbursement To 70% of Medicare

Pathologists contracted with Aetna will see their reimbursement for pathology services drop to about 70 percent of Medicare rates effective Sept. 1, 2014. In letters sent to health care professionals, the payer said it was updating its Aetna Market Fee Schedule based on industry standards and other sources, such as the resource-based relative value scale posted on the Web site of the Centers for Medicare and Medicaid Services. While the letters were initially sent to providers in Ohio, sources say they expect the new fee schedule to be rolled out nationwide. “I fully believe this will be a national policy,” says Michelle Miller, vice president of Vachette Pathology, a revenue management company based in Blissfield, Mich. Currently, pathologists who are out-of-network with Aetna in Ohio are receiving 80 percent to 100 percent of billed charges, so the new fee schedule will represent a significant cut for providers, she explains. For example, one client of Vachette’s had been receiving about $120 in reimbursement for CPT 88305. Under the new fee schedule, that client will now receive payment of $28.14 for the professional component (PC) of the test. In Ohio, Medicare pays $37.52 for the PC, with a global payment of $67.34.

NEW AETNA RATES V. MEDICARE, 2014
CPT CODE	MODIFIER	DECRIPTION	AETNA (9/1/14)	MEDICARE 2014 NATIONAL PAYMENT
88300		Surgical Path Gross	$10.44	$14.69
88300	26		$3.44	$4.66
88300	TC		$7.99	$10.03
88305		Tissue Exam by Pathologist	$50.51	$70.57
88305	26		$28.14	$38.33
88305	TC		$22.37	$32.24
88307		Tissue Exam by Pathologist	$203.18	$288.37
88307	26		$61.77	$84.18
88307	TC		$141.40	$204.19
Sources: Aetna and CMS