Bill to Register MRI Techs Fails to Move

 


 

AB 1092 ( Mullin), as introduced, would have established a licensing mechanism within CDPH to require MRI technologists to be licensed and to be ARMRIT certified. The CRS worked with the author to refine the provisions but remained neutral on the bill. As the bill moved out of the Assembly Business and Professions Committee it was amended to only require an MRI tech to register with CDPH, not meet any certification standard, and exempted any licensed RT who performed MRIs from the need to register or pay a fee. A licensed RT could indicate on their RT renewal with CDPH that they performed MRI procedures. In addition the author added a provision requiring the MRI tech to report any incidents of MRI malfunction to CDPH. At our suggestion that provision was altered to put the reporting onus on the facility.


As AB 1092 moved to the Assembly Appropriations Committee the costs to implement the bill become the focus. The Committee analysis indicated a likely cost of $1M over a two year period that would partially be offset by registration fees. Any bills with new State costs of over $150,000 are sent to the Suspense File and considered collectively with all other spending bills. Yesterday the Assembly Appropriations Committee held, did not pass, large number of bills including AB 1092. That means the bill is dead for the year.



 Bill on Out of Network Billing in Hospitals and

Freestanding Imaging Centers

 

 

There have been multiple legislative proposals to attempt to deal with patients in health plans who obtain services from a hospital contracted with the plan but may have hospital based physicians such as radiologists, ER, pathology and anesthesiology, who are not contracted, out of network, and bill the patient for services. Current law provides that such a patient can't be balance billed for any emergency services needed to stabilize the patient prior to admission.

 

AB 533 ( Bonta), Chair of the Assembly Health Committee, would attempt to address the issue by limiting the patient's charges or cost sharing in such situations. It would require that the patient pay the non-participating provider at the same cost sharing basis as if the physician were in network, i.e. the same deductible or coinsurance as under their plan. AB 533 would also allow a plan enrollee to voluntarily consent to the use of a non-participating provider if they are notified 24 hours in advance, provided a cost estimate, and consent in writing. The out of network physician in either the hospital or freestanding imaging or radiation oncology center would be prohibited from balance billing the patient.

 

Radiology joins other HBPs and the CMA in opposing the bill since it would effectively allow health plans to set the reimbursement rates for non-contracted physicians and groups. Assemblyman Bonta understands the need for balance on this issue and after the bill passed the Assembly Health Committee he continued to work with all stakeholders in trying to determine an equitable solution.

 

The bill was amended recently to include an Independent Dispute Resolution Process (IDRP) where physicians could have a binding process with the plan over appropriate payment for out of network reimbursement. There is a similar mechanism within the Department of Managed Health Care over fee disputes but it is voluntary not mandatory and has not been used. Though an IDRP could be helpful and the bill does allow a provider to aggregate claims under one appeal it would be an expensive and time consuming process for physician groups. The bill would also need provisions requiring plan's to provide an interim payment to the physician.

 

AB 533 was also amended to include language attempting to establish a requirement that plans pay an "appropriate" amount to non-contracting out of network providers. It suggests the Medicare rate plus an additional percentage above that, but has no specific percentage. If this were the ultimate approach it is also clear that the Medicare plus X percent would not be the same for all hospital based specialties. The physician community has argued for a payment based upon charge data, but the author and consumer/ patient advocacy groups sponsoring the bill have argued against charge based solution. Obviously the plans have also argued against that benchmark.

 

The CRS continues internal discussion and with the stakeholders on the provisions of AB 533. The bill will likely move to the Senate next week and the discussions will continue prior to hearings in the Senate.

 

 


 Med-Cal Change in Use of Billing Modifiers Effective 8/1/15

 


Last year we alerted you to a possible change by Medi-Cal to do away with the ZS modifier on radiology claims to indicate a global charge. Though eliminating the unique ZS modifier was a great idea DHCS also would have required that that global charges then be broken into two claim lines, PC and TC. The CRS submitted numerous comments in opposition to the two line process. DHCS recently published the final policy with an effective date of August 1, 2015. It eliminates the ZS modifier and a global charge would contain no modifier. Here is a copy of the notice;

 

Upcoming Changes: HIPAA Code Conversion for Local Modifier ZS

 

An article that published in the April 2015 Medi-Cal Update announced that the effective date for the discontinuation of local modifier ZS would be July 1, 2015. Local modifier ZS designates both the professional (26) and technical (TC) components of a split-billable procedure on a claim or Treatment Authorization Request (TAR). However, in order to allow sufficient time for providers to make the necessary changes, the effective date for this policy is now August 1, 2015.

 

Effective for dates of service on or after August 1, 2015, the Department of Health Care Services (DHCS) is discontinuing local modifier ZS. Modifier ZS designates both the professional (26) and technical (TC) components of a split-billable procedure on a claim or Treatment Authorization Request (TAR). When billing for both the professional and technical components, a modifier is neither required nor allowed. This change is to continue HIPAA compliance efforts and to align with the Centers for Medicare & Medicaid Services (CMS) guidelines.

 

Discontinuing local modifier ZS will affect claims and TARs for all split-billable procedures except for Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA) and Positron Emission Tomography (PET) procedures. See the relevant sections of the provider manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.

 

Note:

Effective for dates of service on or after August 1, 2015, providers who previously submitted claims or TARs for split-billable procedures using local modifier ZS are instructed to submit claims and TARs without a modifier.

 

Claim Completion

Except for MRI, MRA or PET procedures, providers will be instructed to use one of the following methods when submitting a claim for both the professional and technical components of split-billable procedures. See the relevant sections of the provider manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.

 

Physician Billing: The physician bills for both the professional and technical components and then reimburses the facility for the technical component, according to their mutual agreements.

The physician submits a CMS-1500 claim form with the procedure code on one claim line without a modifier in the Procedures, Services or Supplies/Modifier field (Box 24D). 

 

Facility Billing: The facility bills for both the technical and professional components and then reimburses the physician for the professional component, according to their mutual agreements.

The facility submits a UB-04 claim form with the procedure code on one claim line without a modifier in the HCPCS/Rate/HIPPS Code field (Box 44).



CRS Annual Meeting 
October 2 - 4, 2015 
Newport Beach, CA
 

 
Please plan on attending the meeting this year.  You can link to the program here.  We have tried to provide a series of presentations on emerging issues for radiology including new payment models, the growth of the Ca. Exchange plans and next steps, and the evolution of mid level practitioners and the impact on ordering of services.