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Industry Insights

Aetna to end payments for PC of clinical pathology Aug. 1

Aetna will no longer pay for the professional component of clinical pathology beginning Aug. 1.

While the insurer initially ceased in-network payments for the professional component of clinical pathology services around 2005, many groups have remained out of network with Aetna in order to get paid for these services. Others were successful in negotiating payments for these services into their contracts.

Now, it seems they are seeking to close that revenue stream and are essentially writing it off as a payment issue that wasn’t in line with their “longstanding policy,” according to a letter from Aetna being sent out to providers.

The ability to bill for these services typically varies by payer across the industry. For example, Cigna will pay for the professional component of clinical pathology, while UnitedHealthcare will not.

The following 80000 series CPT codes are the only services Aetna will reimburse with a -26 modifier moving forward:

It’s currently unclear whether or not group’s who have negotiated specific payments for these services will be affected by this change.

While the overall impact of cutting reimbursements for these services will vary by provider depending on your overall Aetna volume and whether or not you were already precluded from billing for these services due to contract language, this is just another example of a revenue stream being eliminated as pathologists and labs continue to be put in financial constraints from the trickle-down effects of PAMA.

This is why labs need to have a sound revenue strategy in place as various payers continue to close off previously viable revenue streams.

Interested in learning more about coding audits or improving your overall revenue cycle management? Contact us today for a free consultation.


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