Aetna to require CAP or Joint Commission accreditation for in office anatomic pathology labs

I read about this in the April edition of Laboratory Economics, which is an excellent publication.  For those that do not subscribe, I will quote some of the interesting parts from the article:

The new Aetna requirement for CAP or JCAHO accreditation for in-office pathology labs be­comes effective August 1, 2012. The requirement applies to both the technical and professional component of services billed for CPT codes 88300-88314 and 88342.

Finally!  A private carrier is standing up for patients and requiring proper accreditation if these docs want to get paid for self referral of anatomic pathology services.  In addition, what a great opportunity for the CAP to stand up for the majority of its members and say they will not grant accreditation for an in office anatomic pathology laboratory.  After all, if in office labs cannot easily achieve accreditation, then perhaps some in house labs will close, utilization of pathology services will drop, patients will not have unnecessary biopsies done purely for profit, and independent and hospital based pathologists can start to recover specimens that have been taken away for unscrupulous reasons.

Is that what the CAP is doing?  It doesn’t appear so, at least not at this point.  Instead, they have made a handy dandy web page to help in office lab owners navigate the accreditation process more easily.

Why would they do this?  I wonder if it’s because they can make money from it.

CAP says that the application fee for accreditation is $799. In addition, CAP says that its accredi­tation program costs the typical in-office pathology lab about $1,400 to $1,600 per year, depend­ing on the complexity and volume of tests.

Hopefully we will soon learn why CAP has decided to play ball.

Moving on.  Also from the article:

The new accreditation requirement will be a “big stumbling block” for smaller in-office pathology labs (<3,000 cases per year), says John Cochran, MD, chief executive at Chestatee Pathology As­sociates (Smyrna, GA). But he also says that accreditation is “a major step toward universal accep­tance” of the in-office lab model. “It will help legitimize these labs by ensuring that quality patient diagnostics is the main concern, not profit. As both a fellow in CAP and as a physician surveyor with The Joint Commission, I know that both organizations will help ensure CLIA standards compliance and the highest quality patient diagnostics.”

“Many pathologists do appreciate the need that in-office labs serve, but either don’t have the time to voice their opinions or are afraid to, given the vitriolic attacks by the naysayers, who are invari­ably hospital-based pathologists who have lost business to in-office labs,” adds Cochran.

In my opinion, accreditation of a lab does absolutely nothing to “ensure that quality patient diagnostics is the main concern, not profit.”  The two are not mutually exclusive.  These in office lab owners will look at the accreditation as merely a $1500 per year decrease in profit.  If they were truly concerned about putting quality over profit, wouldn’t these labs have voluntarily sought CAP or Joint Commission accreditation prior to this requirement?  Even for the best labs in the world, profit is still a main concern.  It has to be.  Without meaningful profit, a lab would cease to exist, unless of course it receives funding from somewhere else.

If profit was not a concern, these clinicians would simply find a pathologist that best suits the needs of their patients and allow that pathologist to bill global for their services.  But they don’t, so profit is the main concern and will remain so even after they gain accreditation.

I am also interested as to how in house surgical pathology labs contribute to patient care with respect to the intent of the in office ancillary exception to Stark.  Are these labs magically able to process and diagnose these biopsies during the same patient visit?

I sent an email to Dr. Cochran asking him some of these questions.  I will post his responses when I receive them.

Aetna is pushing for this accreditation to happen very quickly, and many in house labs will not be able to make the deadline.  So this makes me wonder whether they really want these labs to be accredited in the first place or if there is another motive at play here.  Then I read further:

Aetna says that in-office pathology labs that do not obtain these credentials by August 1 must refer their Aetna patients to other in-network pathology labs. Aetna’s preferred labs are Quest Diagnos­tics and AmeriPath, including its Dermpath Diagnostics division.

And there it is.  This could be just another example of the pull through agreement that Aetna has going with the Quests and LabCorps of the world, for which they are currently under investigation by the federal government.  Indeed, according to a recent post on Histonet, Aetna is not even telling people about other CAP accredited non-hospital labs to whom they can send specimens if their current lab fails to meet the deadline–they are telling them to just send them straight to Quest/Ameripath.

Comments

  1. Anonymous says:

    There are several in-office pathology labs with GI-pathologists and uropathologists on staff, who from a quality angle and sophistication, currently outshine most, if not all, pathologist-run labs when it comes to subspecialty pathology services. These in-office pathologists are your colleagues and are no more or no less ethical than the majority of pathologists. They earn a living and put their pants on one leg at a time just like you do. Your statement that CAP should state , “they will not grant accreditation for an in office anatomic pathology laboratory” speaks volumes about you, your specialty and its College as an accrediting agency.

    • A says:

      Thank you for the comment. I will be doing a post on your comment tomorrow and in it I pose questions to you. I hope you will answer them and contribute further to the debate. Thanks again.

  2. Mark Allshouse says:

    In response to those who have concerns with the quality of diagnostic material (slides and stains)
    that are produced by in house histology labs I have some personal observations.
    I have been a board certified Histotech for over 35 years and have worked in and managed pathology labs in large teaching hospitals, smaller community hospitals, and a large regional pathology group lab. Three years ago I was recruited by a Dermatopathologist to establish and run a histology lab for his Dermatology group practice. After this experience I can say with no reservation the quality of the slides exceeds any material that came from the other laboratories I worked in. Why?
    In my current lab I receive and accession the specimen, perform the gross examination, including speaking with the provider who submitted the specimen if I have any questions about the specimen, process the specimen, embed the processed tissue, cut the slides, stain the slides for either routine or special stains, print and distribute the completed reports, file and maintain the slide and block archive, and preform all of the quality control and assurance as well maintenance on all the equipment, materials and reagents.
    In a regional, or national pathology laboratory, specimens are picked up by a courier, and delivered to the laboratory. The specimen is then accessioned by a non-technical staff member, gross examination is performed by a Pathology Assistant, then embedded by a Histotech, slides are cut by another Histotech, routine staining by another Histotech, special stains by another Histotech, and ultimately, the slides are sent to a pathologist who may not even be in the same town as the laboratory, the report is then typed by transcription staff, and then either electronically sent to the provider or sent by courier.
    From time of receipt by a courier to the time a report is in the hands of the provider, this specimen can go through as many as nine individuals.
    The area of greatest concern is getting the lesion the provider saw, on the slide. In many cases the PA who performs the gross has no idea which Histotech will be embedding the tissue and which Histotech will be cutting the slides, so the very small lesion the provider observed on biopsy, and the PA saw on gross examination, never makes it on the slide. If it doesn’t it’s not a negative reflection on the PA or the Histotech’s skills. Both the PA and the Histotech’s have hundreds of biopsies to deal with every day and many laboratories never even see one another.
    When a provider brings a specimen in to our lab they can point out the area of interest on the specimen, observe how is it is grossly examined and submitted, and after processing you can be assured that I will embed and cut that specimen ensuring the area of interest will be on the the slide so it can be evaluated and diagnosed by the Dermpath.
    I believe that this is one of many reasons a Physician Office pathology lab is at least on par if not superior to a national or regional pathology laboratory.

    • A says:

      Mr. Allshouse,

      As I said in the post entitled “Yet another interesting urologist comment about in office labs”, I agree there are many aspects to in office labs that likely contribute to better patient care, and your experiences with an in office lab attest that quality can be very good. However, your n=1 experience cannot be generalized to every in office lab in this country. In addition, the point of my writings against in house labs is not that they provide poor quality; it is that they can lead to abuse, unnecessary procedures and increased global health care costs, because the (in your case) dermatologist owners have every incentive to process as many biopsies as possible.

      Unfortunately, as a histotech, you probably are not in a position to be able to judge what biopsies you process are truly clinically necessary, and that is the key metric. As Dr. Mitchell’s study showed, self referring urologists detected cancer far less than non self-referring urologists, meaning they biopsied too many people. It would be interesting to see how many seborrheic keratoses, acrochordons, banal nevi, etc are biopsied in your lab that may not have been elsewhere were the financial incentive to biopsy absent. I am of course not accusing your lab of anything. I am merely saying it would be interesting to do a study. That is the only true way to see if overutilization is occurring, but for obvious reasons, I doubt there are many, if any, in office labs that would be willing to open their practice (including billing invoices and matching pathology reports) to an independent reviewer. I have yet to see a study like that, and in office labs have been around for 7 years at least, and pod labs before them.

      In the end, regardless of quality, in office labs are all about money for the self referring docs, no matter what their advocates say. Think about it. You could keep your lab and all of its patient care benefits you listed, but take away the self referring dermatologist’s cut, and nothing would change from a patient care standpoint. Have you ever heard of a clinician that allowed a pathologist to open a lab in their office and to bill global for their services simply because of the patient care benefits of an in office lab? I haven’t. Please let me know if you’ve heard of one, because I don’t think they exist. Because then the referring clinician would not be able to unethically make a profit from work they don’t do, and that’s what they really care about. And they want that money–badly. As I’ve said before, it really is that simple.

      Thanks for the comment and for reading the blawg.

  3. dermatologist view says:

    Hi, I am a board certified dermatologist. I set up an in house dermpath lab two years ago. I am not a dermatopathologist. And, I do not have a pathologist working in my lab. I am the lab director and I am the physician. Stark law does not considered a specimen sent to my very own lab a referral. I am surprised at the number of pathologist that tend to focus on what- a- -dermatologist is doing. In the end, pathologist are only hurting themselves. Prior to establishing my lab, I use to send mine our for the technical component and bill global. However, due to the Medicare regulations, I opted to start my own in-house lab. My lab is CLIA certified and it is extremely well run. When I had my CLIA certification, the inspector told me that I was “doing too much quality control”. I am the lab director. And, I have a histotech that works at Quest full time. She comes to my office two days per week after 4p.m. to process my specimens. It is a small mini lab. I only run pas and HandE stain. If I need an additional stain (based upon the possible differential diagnosis), I will send it to my consulting lab with a board certified dermatopathologist. 95% of my lab work is kept in-house. For such a small lab, it is was not cost effective to run every stain available.

    Instead of worrying about what dermatologist are doing, pathologist need to really look at what Quest and Labcorp are doing. Pretty soon, pathologist will be standing in soup kitchen lines for food if they do not stop the monopoly behind Quest and Labcorp. Aetna is trying to weed out ALL labs to fuel the “pull through”scheme. Pathologist need to be concerned about this, not about what dermatologist are doing.

    Don’t hate- on dermatologist. We are trained to read our very own slides. In fact, dermatologist have more training in “skin” pathology than general pathologist!

    Now, the Aetna scheme may sound good to you, but, in the end, pathologist will be hurt by this, not dermatologist. The latest is that Aetna will require CAP or Joint Commission certification. I have already signed up for JC inspection for June 2012. The American Academy of Dermatology has met with Aetna to see that dermatologist are not subjected to CAP certification. All the complaining that pathologist have done over the years, only end up hurting themselves. Prime example, the new Medicare rule that pathologist supported. Well, guess what?dermatologist got smart and started setting up their own labs.

    Pathologist should save they energy fight Aetna, LabCorp, and Quest. They are forcing you to accept below market rates to run your labs without the benefit of a “kickback”. This is what pathologist should be focusing on…..

    Dr. G

    p.s. excuse any typos

    • A says:

      Dr. G,

      Thank you for your comment. I agree with you that dermatology should not be our focus with respect to in office labs and it is not for me; dermatologists receive plenty of microscopic training in residency and are more than capable of performing their own microscopy for the majority of their cases. I don’t think I have “hated” on dermatology for this reason on this blawg. As long as they do not over utilize, I actually have no problem at all with derm in office labs. My problems lay with those providers that do not have sufficient (or any) microscopic training (urology, GYN, GI) that have labs, because they are not actually doing any of the work from which they are profiting.

      That being said, there are many dermatologists out there that live in states that allow client billing that send their specimens to a completely independent lab in which they have no capital investment (unlike in office labs) and can still take the majority of the pathologist’s fees for themselves. It is legal in my state, and it affects my practice, as they send the cases out of state so they can make money from the referrals, instead of sending it 5 minutes away to my lab which has two board certified dermatopathologists. These dermatologists can make just as much money, but they do not have any malpractice exposure, as they are not the ones looking at the slides. It is sickening, unethical and unprofessional, but they are making a lot of money from it, so they care not about the ethical or professional issues.

      Just curious, for those 5% of cases you have to send to another lab, do you make any money from the referral, or do you allow your consulting dermatopathologist to bill global and keep all they earn?

      I did mention at the bottom of the post about the Aetna requirement that it was likely all part of their pull through arrangement with Quest, so I agree with you completely on that issue.

      There is little that pathologists can do to fight LabCorp and Quest. They are so gigantic as to be almost untouchable. Fortunately, their own business practices (pull through, Medicare fraud) may lead to some damage to their infrastructure.

      Thank you again.

      • dermatologist view says:

        When I send to the board certified dermatopathologist, I send the entire specimen. I do not make any income on those. I would not want to bill for 88305 to process the slide when I know in advance that I do not have the special stains. It ends up costing more that way. Some doctors may “cheat” by processing the specimen in-house and sending the slides to dermatopathologist for consult. I do not think that this is right.

        In terms of LabCorp and Quest, insurance companies do “force” physicians to use Quest and Labcorp. I think at some point physicians across the board need to stand up to these insurance companies. I do know the Aetna CAP issue has caused an uproar and several meeting between the AAD leadership and Aetna have taken place.

        I am the ONLY general derm with a lab in Georgia. Most docs send out for the technical component. And, yes, I do believe that most private payers will eventually follow suit with Medicare (that is why I started my own lab early). When the private payers follow Medicare, most dermatologist will not be able to read their own slides unless they prepared in advance (like I did).

        Honesty, I do feel bad for pathologist. Quest and Labcorp want to take all of the business from hard working doctors and filter it towards a handful of physicians. This is starting to look like racketeering. The AAD is watching-like-a-hawk. I hope that pathology organizations understand that the lab giants want to take their specimens too!

        I agree that this is a part of the pull through scam. Believe it or not, the medical director for dermpath diagnostics came to my office last week to solicit Aetna business.He entered my office with his office assistant. They asked my staff who did I use for dermpath. My staff told them that I had an in-house lab. They went on to say ” We are here to help her out. Aetna will not pay if she is not CAP certified by August 1st. We really want to meet with her to discuss the various ways that we can accomplish this. We can help out with the Aetna patients”—-a real hoot! Now, who do you think is behind that letter?

        I was shocked! I immediately notified the American Academy of Dermatology about these visitors.
        That was when I knew that this was part of the pull through scheme. Pathologist should be very concerned about this……………

  4. dr st paula says:

    i respectfully disagree with the other reply. i dont think general dermatologists should be reading their own slides and doing their own labwork. i dont think you should be doing pathology at all. i dont think you are qualified. i think your a greedy unethical dermatologist who has been doing another specialty to only make money without the proper training and have been brainwashed by the AAD propaganda machine to usurp another specialitys area and give yourself SELF referrals for MONEY. most pathologists sign out 100 percent of all their cases correctly without sending any out. the fact that you only can sign out 95 percent of your cases is really pathetic. i can just imagine the mistakes you are making with the 95 percent you are confident on. you are not qualified to medical direct a lab either. your are using that unqualified histowreck from Quest to medical direct themselves and you dont have a clue how to supervise them. have u ever grossed in? you have usurped another specialty for money. it is a scope of practice issue. the dermatologists are infuriated when other groups do their specialty with minimal training but u expect us to back off when your group makes its claims. you claim you did three quaters of a year of pathology and you claim you are qualified versus my six years of pathology training. i guarantee i could find hundreds maybe thousands of errors in your puny slide file. you are probably under and overcalling cases and letting your clinical thoughts rule. i have never met a dermatologist i would show a slide to over a pathologist in my life. you are so egotistic pathetic and pompous to say what you are saying its incredible. 16 percent of dermatologists are still reading their own slides acc to AAD. at least most of your colleagues are wise enough to get out of the slide reading business and leave it to the experts…the pathologists. i agree with you 100 percent on the big box labs and insurance companies that we need to fight but we need to stop inhouse labs for you derms as well. you are a mostly crooked bunch like the urologists. u just have a better lobby. i want the remuneration to dry up on AP to get you amateurs out of our specialty. you and your AAD lab task force give pathologists a bad name. you and your fee splitting marqis pathodermatologists who have made 100s of millions on their fee splitting arrangements with their crooked colleagues. i hope they drop the global fee to ten dollars like a conventional PAP so we get you out of our speciality. you derms are going to be on the soup lines once these ACOs come. enjoy your million dollars a year while it lasts. your days of greed and abuse are almost over. i cannot wait to see nothing but only necessary biopsies one day when this is exposed for what it is. please ask yourself each day. do i really need this biopsy? is this biopsy cosmetic? can i treat this without making swiss cheese out of my patients? i guarantee you can cut your biopsies in half. dr stp

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  1. Is the AUA really claiming urologists with in office labs are “struggling” financially? says:

    [...] “struggling” financially? June 20, 2012 By A Leave a Comment Almost two months ago, I did a post about Aetna requiring either Joint Commission (JC) or CAP certification for in office labs, or else they will [...]

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