Following a request for additional details on its payment policy change, Cigna provided the CAP with its updated policy to deny claims for the professional component of clinical pathology (modifier 26; PC of CP) when billed by pathologists. The CAP has opposed policy to deny payment and has urged the insurer to continue paying for the PC of CP services for all pathologists.
The CAP further pressed Cigna for additional details after the insurer acknowledged the role of pathologists in providing laboratory management and oversight services, which are key to reliable and accurate diagnosis and treatment of patients. In a letter to Cigna on October 26, the CAP requested needed clarification on how Cigna proposes to operationalize its policy and ensure pathologists receive appropriate payment for these services.
In late September, pathologists and laboratories began receiving letters from Cigna stating that the insurer would go forward with an updated payment policy on PC of CP, which it had previously tabled following opposition from the CAP and pathologists from around the country. The CAP contacted Cigna officials to get additional information and discuss concerns pathologists have with the policy.
In response to the CAP, Cigna stated in its new policy that it: “will issue denials when the facility where the services were provided is contractually responsible for laboratory management and oversight services.” Furthermore, in response to CAP questions, the insurer indicated that this policy “will apply to both employed and non-employed pathologists working in or for facilities that are responsible for laboratory management and oversight services through their Cigna contracts. This is indeed analogous to how [the Centers for Medicare & Medicaid Services (CMS)] approaches this issue.”
In April, Cigna had initially announced the payment policy change would take effect in July (but eventually decided not move forward with the policy until recently). In communications to Cigna, the CAP maintained the PC of CP services are critical to the reliable and accurate diagnosis and treatment of patients. In a letter to Cigna on April 23, the CAP urged Cigna to continue paying for the PC of CP services for all pathologists and highlighted the fact that under Medicare policy the CMS pays pathologists for these services under its Part A benefit.
Under Medicare Part A, a payment amount is assigned to each diagnosis related group (DRG), which is for the full spectrum of services received by the patient, including PC of CP services. Hospitals then pay pathologists for such services at fair market value. Additionally, there are several clinical pathology procedures that Medicare reimburses under the Part B for physician services.
The CAP remains engaged on this issue and will seek additional clarifications on Cigna’s policy. The CAP will continue to keep its members updated on the latest developments concerning Cigna and payment for the PC of CP.
