prior authorization for IHC?

[SEpathguy]

Has anyone ever heard of this as a future possibility? Someone I was talking with said he's heard its possible insurance companies could start asking for prior authorizations for immunostains. Of course this would be crazy, annoying, kill turn around time, etc. but doesn't mean they wouldn't try it. I'm interested to hear people's thoughts on the subject.

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[Alteran]

I'd sign everything out that I know would require IHC as "atypical - see comment" and explain that a definitive diagnosis will require further workup if clinically indicated. I may put in a disclaimer at the bottom of the report stating that IHC testing requires insurance approval, which could delay or modify future therapy.

 

[LADoc00]

Hahahahaahahhaahahaha. No way this would occur.

1.) technically they arent "new orders" they are reflex texts
2.) the $$ is too small to bridge any comparison to things like pre-approval for PET scans

but would be funny to think about.

 

[Autopsy101]

Has anyone ever heard of this as a future possibility? Someone I was talking with said he's heard its possible insurance companies could start asking for prior authorizations for immunostains. Of course this would be crazy, annoying, kill turn around time, etc. but doesn't mean they wouldn't try it. I'm interested to hear people's thoughts on the subject.

I have heard the same thing - that there are serious moves in the insurance industry to do this.

 

[SEpathguy]

Can you imagine what a negative impact this would have on patient care? Sure, some people do order too many stains, that's almost certainly true. But those same people will always be able justify the stains to someone requiring a prior authorization. The only impact it would have would be negatively impacting patient care / turn around time. I doubt it would save much money at all. I was hoping everyone would say about the same as what LADoc said.

 

[cmz]

This may put unnecessary burden on the pathologist to possibly hire someone that puts all of their focus on handling paperwork necessary for obtaining authorization to perform IHC. This is already happening with certain molecular tests, etc. Let's say for sake of argument that you decide to not hire a person for this task... you're going to get A LOT of denials for the work that you think was necessary to begin with.

It's getting a lot harder to do our job and do it in a timely fashion.

 

[27G]

All stains..... or possible abused stains like H. Pylori and Sox10? As you know CMS does not allow up front special stains like Alcian Yellow without path preview while many private carriers do. It seems unlikely that all stains would need preapproval. There are some “abused” upfront scenarios that get people’s attention..... possibly in working up a lymphoma. Not sure how this could ever become a universal thing especially since CMS is usually the most stringent and private eventually follows. Have not heard about this remotely for Medicare except special stains like Alcian Yellow and that’s because you can upfront those on the line with every upper endoscopy and the technical is very lucrative.

 

[AZpath]

Easily could happen in today's environment. We don't do a good a job as a industry and it has gotten worse and worse. The worst actors are usually commercial labs and in office pathology.

 

[Dave CX]

Easily could happen in today's environment. We don't do a good a job as a industry and it has gotten worse and worse. The worst actors are usually commercial labs and in office pathology.

Once again we see good vs evil. The saints of hospital labs and the evil outpatient biopsy folks. BS.

 

[Vicinal]

Why all the negativity toward commercial labs and "office pathology". If derm, GI, Gu docs did not make money off biopsies they would move to other ways of getting to treatment and therapy. And there are lots of little BS biotech firms trying to bypass tissue.... Liquid biopsies, confocal endoscopy etc. These specialties make billions of dollars off the biopsies they generate. If this were not the case pathology diagnosis would easily be kicked aside over the coming years. It is a crappy relationship path has to these specialties unfortunately but it keeps the meat flowing.

 

[WEBB PINKERTON]

The negativity should be directed at what is happening to the cost of health insurance due to everyone trying to "get theirs".

It does get my blood boiling that there is a piece of legislation trying to get passed that would require medicare to pay for DNA testing on prostate biopsies. The sponsor of the bill received contributions from urology groups with in-office labs.

 

[AZpath]

Why all the negativity toward commercial labs and "office pathology". If derm, GI, Gu docs did not make money off biopsies they would move to other ways of getting to treatment and therapy. And there are lots of little BS biotech firms trying to bypass tissue.... Liquid biopsies, confocal endoscopy etc. These specialties make billions of dollars off the biopsies they generate. If this were not the case pathology diagnosis would easily be kicked aside over the coming years. It is a crappy relationship path has to these specialties unfortunately but it keeps the meat flowing.

No doubt these relationships help support a market for us. Who owns the lab is not really the issue IMO. True, some hospital groups are just as bad.

Right now in the government or payor world cost is king. This is the big risk. I worry we will kill the goose that lays the golden egg.

The Medicare LCD is arbitrary on upfront orders some are ok and others not ok.

The problem is the CMS actually decided this policy with no input from pathology experts or real scientific basis.

You don't want to see more of this no matter who is to blame. Some of the blame is progress.

We can do more and more with IHC. Most of these application are good and growing.

 

[yaah]

Why would they do this when they could just stop paying for them?