Cigna Moves to End Reimbursement for Professional Component of Clinical Lab Services

posted: May 3, 2021

Cigna has announced that as of July 11th, it will stop paying the professional component of clinical lab services to many pathologists.

What, exactly, does this mean?

Pathologists, like all physicians, get paid for professional services rendered. However, unlike most physicians, we have two fairly disparate revenue sources. One revenue source is the work we do on the anatomic side (i.e. CPT codes like 88305). There is also a list of around 20 CPT codes for clinical lab services that are billed in a similar manner — things like electrophoresis, hematology slide review, transfusion reaction interpretation, etc.

The other bucket of revenue is for the services we provide as medical directors of labs. This is kind of an amorphous category, including things like the time we spend reviewing quality control and providing clinical lab consultations, but it’s vitally important to ensuring optimal patient care. Medicare long ago decided that the easiest thing for it to do would be to pay hospitals for these services, and then the hospitals would pay pathologists. This is the Part A payment we all love, and we get paid by negotiating our fee with our hospitals.

However, Medicare only pays hospitals to take care of Medicare patients, and we provide clinical lab services for ALL patients. So many pathologists have billed insurance companies for these services. And most insurance companies, in turn, have paid us, although with enough roadblocks to make it sometimes pretty difficult. But they seem not to like the arrangement. Every once in a while, one will try to stop reimbursing us for this work, claiming that Medicare doesn’t pay us so they won’t either. Technically, this is true, as Medicare pays hospitals and then hospitals pay us. But it’s kind of a lousy argument. And, in most cases, the insurance companies are not offering to pay the hospital (like Medicare does) – they just want to stop paying anyone. Because, you know, we should work for free.

There are many different ways pathologists’ contracts can work, depending on whether you are a small private practice, part of a large healthcare system, or within an academic center. As your individual situation is unique, how to negotiate with the insurance company will vary. The negotiations may need to involve discussions with your hospital. The CAP has excellent resources which may be helpful.

If you are potentially affected this Cigna move, the company should have sent you a notice. But even if Cigna’s move applies to no pathologist in Georgia, the GAP feels it is important for its members to understand the dynamics of the situation. There will always be a next time.