Utilization Management in Anatomic Pathology

Abstract

From the perspective of utilization management, surgical and cytopathology are fundamentally different from laboratory-based testing in that billed revenues include both a technical component (part A) and a professional component for physician services (part B). Due to the professional billing component under fee for service, there can be a disincentive for anatomic pathologists to engage in utilization management which could impact practice revenues. Unlike clinical laboratory testing where clinicians are often leaders in utilization management initiatives, in most cases clinicians are unaware of mis-utilization of anatomic pathology services. Consequently there are relatively few published studies concerning utilization management in anatomic pathology or cytopathology. Nonetheless a review of the literature combined with personal experiences reveals a number of potential utilization management opportunities that can be successfully implemented in anatomic pathology.

Beyond the impact of utilization management on practice revenues, there are also significant medical-legal issues that create barriers to utilization management in anatomic pathology. Failure to adhere to the standard of care in the evaluation of anatomic pathology specimens may result in lawsuits for negligence with significant adverse consequences for the pathologist. Looking to the future, the transition from fee-for-service reimbursement to bundled payments for entire episodes of care (or entire populations) will create new incentives for improving utilization management in anatomic pathology. To help guide this effort, it will be important for pathology professional societies such as the College of American Pathologists to develop appropriate standards of care for the evaluation of anatomic pathology specimens to assist practicing pathologists in establishing a utilization management program in their practices.

Portions of this chapter were derived from a recent review by the author published in Clin Chim Acta. 2014;427:183–7.