New Threat to Community-based Anatomic Pathology

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THERE IS A NEW DEVELOPMENT that may be off the radar screens of CAP, ASCP, and the various subspecialty pathology associations. It is the requirement for second reviews and subspecialty reviews of certain complex pathology tests as part of the laboratory benefit management program (LBMP) ready to launch in Florida.

Enforcing this requirement for lab tests done on UnitedHealth patients in Florida will be BeaconLBS, a wholly-owned subsidiary of Laboratory Corporation of America. Some alert pathologists have already recognized that a payer requirement for second and subspecialty reviews for complex pathology procedures will work against general practice pathology groups serving community hospitals. In that regard, it can be considered the newest threat to the private pathology practice business model.

You should read our coverage that follows of the UnitedHealth and BeaconLBS prior authorization pilot program to better understand its goals and the role of the second/subspecialist review requirement. Pathology Blawg, commenting about the lab benefit management program, had this to say:

Basically, the LBMP mandates essentially all malignant and pre-malignant diagnoses must have a second review in order for the claim to be paid [by UNH], and in many instances it requires a sub-specialist to perform the second review.

Board-certified anatomic pathologists will no longer be permitted to sign out [under the UnitedHealth LBMP] any malignant cytology or derm cases, or any lymphoma specimens (both nodal and extra nodal), without a second read by a pathologist who is board-certified or board-eligible in that sub-specialty.

In addition, any labs which sign out bone marrow studies must have sub-specialty certification in hematopathology.

Pathology Blawg goes on to say, this “will most definitely be a significant hardship on small pathology groups and hospitals, especially those in underserved areas, that rely on pathologists with only AP or AP/CP certification.”

Do pathology associations want a payer (possibly influenced by its national lab collaborator that competes with local pathology groups) to establish a requirement for lab payment that goes beyond today’s accepted standard of clinical care? And would that payer exclude properly trained and licensed pathologists from providing the current level of patient care that they do? Community pathologists may want to alert their professional associations to this development.

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