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Florida Society of Pathology Pushes to Retain PCCL Reimbursement from Medicaid

  • Director of Anatomic Pathology Development

Florida Society of Pathology (FSP) held a call for members on July 15th to review the process the organization had taken upon learning the state’s Medicaid plan would no longer fund Professional Component of Clinical Laboratory (PCCL) reimbursement. Florida is among less than a handful of states, including California and Illinois, that sill receive reimbursement for PCCL charges for Medicaid patients.

These efforts remind us that pathologists and the organizations supporting them, such as FSP, CAP, etc., are our industry’s best advocates. The FSP’s approach with the payor was collaborative and thoughtful. As such, the payor was receptive to hearing the group’s position, reviewing previous legal precedence, and ultimately reconsidering its previous determination. FSP’s strategic efforts in leveraging the appropriate contacts within its own network, backed by strong legal representation, has led to an incredibly successful outcome. That said, these successes are within individual battles, not the whole war, and the need to fight for the right to reimbursement is ongoing. The passion to advocate for one’s means to survive in an ever-challenging and changing marketplace must not be lost. It’s important that pathologists realize the significance of their voices and the outcomes that can be accomplished when they strategically align goals and allow themselves to be heard as a unified army of physicians.

Takeaways from the FSP Webinar:

  • Some carriers reversed Professional Component (PC) reimbursement on PCCL claims and paid globally in error. Pathology practices need to audit PCCL charges to ensure they are being reimbursed correctly.
  • Previously denied claims for Non-HMO payors can be resubmitted through normal resubmission processes; however, it is likely denials from HMOs will need to be appealed.
  • Review payor agreements to see if you are entitled to PCCL reimbursement. Also check commercial contracts tied to Medicaid.
  • The fight is not over. There is a lot of effort to tie Medicaid reimbursement to Medicare standards. It is important we continue setting the precedent this is standard of care and billing in Florida. The fewer who participate, the greater the opportunity for Medicaid of Florida to justify discontinuing the practice.
  • Until the formal fee schedule has been published, FSP is urging members to contact FSP leadership directly if there are questions around the updated AHCA/MDFL policies. It is expected the updated fee schedule will loaded by the end of July.

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