Medicaid Alert for Florida Pathologists

The FSP has recently become aware of a significant change to the Practitioner Laboratory Laboratory Fee Schedule, as promulgated by Florida’s Agency for Health Care Administration (AHCA), which, as you know, administers the Florida Medicaid program, a $24 billion dollar program, and publishes the many physician fee schedules applicable to the program.
We became concerned when we noted that the proposed 2020 Practitioner Laboratory Fee Schedule lists only about 70 clinical lab tests that are CP PC-reimbursable, as compared to over 1,000 such tests in the 2019 schedule, despite the fact that the “global fee” is essentially the same for the two schedules (AHCA calls it the “FS”), meaning that a pathologist entitled to Medicaid reimbursement under the schedule would - under the proposed 2020 schedule - be paid the same in the current year for such a test as the previous year, despite the fact that the PC component is no longer listed. Take, for example, one of our most common tests, 85025 CBC w/ automated diff, wbc. You will note that the 2019 schedule pays $6.48, and includes a $1.30 PC payment, and the 2020 schedule pays the same $6.48, but, significantly, the PC payment has disappeared. A comparison of the two schedules quickly shows that about 1,000 tests have lost their PC component in the proposed 2020 schedule.

While one might be lulled into complacency by merely comparing the global fees for both years, we became concerned that the omission of 1,000 CP PC-reimbursable lab tests no longer had a number in the PC column. The 13 Florida Medicaid payers might seize the opportunity to, going forward, deny PC payment for these “dropped” tests, citing the AHCA Rule 59G-4.002 as published. Sound familiar? Yes, the pathology community, nation-wide have had their CP PC component under siege for as long as we can remember, and even though, historically, Florida has been among only a few states (like Illinois and Virginia), we became very concerned that this might well represent another opportunity for the insurance industry to do battle with us over our PC opponent.
Accordingly, the FSP has held several conference calls and exchanged emails with a number of interested parties, including experts in the billing sector, the Florida Medical Association, and College of American Pathologists, and have also held two conference calls with AHCA. Their response focuses on a single theme - “we are only following what the CMS, in their Clinical Laboratory Fee Schedule for Medicare B laboratory testing, publishes.” Indeed, the HCPCS and CPT codes for their Fee Schedules for Outpatient Laboratory testing are the exact same list as AHCA’s, and the Agency assured us that they use a modifier algorithm, based on CLFS, to determine the Florida Medicaid allowances. When prompted to comment on the potential impact of the 2020 Fee Schedule, as compared to the 2019 listing, the Agency demurred, reverting to their assertion that “…(all we did) was copy the CLFS.”
As you know, the Florida Medicaid clinical laboratory business is a $400 million dollar business, so we engaged the FSP General Council, on a limited basis, to advise us and communicate with the Agency. In that regard, we think it is vitally important to keep the pathology community informed and gather your input, and so will be holding a Town Hall Webinar on Wednesday, July 15 at 7 pm ET for you to hear from our experts, learn the latest information, ask questions, and share your experiences. We urge all of you to attend this important, if not landmark, event. We will be sharing further updates on this event including how to register in the coming days. 
Make no mistake about it. The FSP is fighting for you! We don’t know where this is headed, but, if necessary, we are prepared to challenge this action as vigorously as possible, up to, and including, litigation to ensure that Florida’s historic policy of reimbursing the PC component of outpatient clinical laboratory testing be upheld.

As a result of our initial efforts, just moments ago, we learned that AHCA has agreed to schedule a Rules Workshop, a public meeting (most likely held virtually) that you and any member of the public can attend. This is a very significant development, indicative of the pressure we have already brought to bear on the Agency. As soon as the date is announced, we will let you know. This is an opportunity for us to present our case and hear from you with your questions and concerns.
Please feel free to email us or call me directly at 850-251-9917 if you wish to share your concerns and experiences, and I look forward to seeing you at our Town Hall Webinar on July 15. Continue to visit the FSP website for more information regarding important updates on this issue and further details regarding the Town Hall Webinar. 
Best regards,
Morton H. Levitt, FCAP, MHA, MD
President, Florida Society of Pathologists
Mobile: 850-251-9917

Publication Date: 
Tuesday, June 23, 2020 - 1:00pm