Aetna, Anthem to Pay Pathology Groups Less

TWO OF THE NATION’S LARGER HEALTH INSURERS—AETNA AND ANTHEM— ARE CUTTING WHAT THEY PAY for the professional component of certain clinical and anatomic pathology codes.

In its communications with pathology groups about this policy change, Aetna says it will no longer pay for most clinical laboratory claims submitted with the modifier 26 for professional component services. It says this step is to align current practices with its longstanding policy of not paying a professional component for clinical pathology professional services. Some national pathology billing experts believe there are certain pathology groups that stand to lose as much as $300,000 per year in revenue from this change.

By contrast, Anthem’s actions are more troubling for the pathology profession as a whole. State-by-state, Anthem is pushing two major changes onto anatomic pathology groups. One change is to terminate the pathology group’s professional services contract and move the group to a laboratory contract, handled by the insurer’s ancillary services contracting department.

The other change is to reduce what it pays for nearly all the anatomic pathology CPT codes by amounts reported to be 50% to 70% less than what it currently pays. Anthem gives pathology groups a limited number of days to accept or reject its offer. There are reports that—after certain pathology groups chose to reject the offer and go out of network—representatives from Anthem went to the hospitals and health networks served by these pathology groups to inform them that their anatomic pathology provider had opted to cancel its Anthem contract and go out of network.

It is easy to simply categorize the actions of Aetna and Anthem to cut prices for pathology services as their response to the PAMA-related cuts to Medicare Part B lab test fees. After all, across the nation, reports are pouring in about how state Medicaid programs and private health insurers are following Medicare’s lead and cutting what they pay laboratories.

However, deeper changes are happening among the larger private health insurers. These current actions should be seen in context of how other insurers are instituting prior-authorization requirements, narrowing provider networks, and refusing to cover many new lab tests.


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