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July 20, 2015   



Out of Network/Balance Billing Prohibition
Passes Senate Committee


Last Wednesday AB 533 (Bonta) passed the Senate Health Committee. There have been multiple amendments made over the past week and additional amendments were taken in Committee at the request of the Committee chair Sen. Hernandez. The CSP remains in opposition to the current version of the bill along with the CMA and other medical specialty societies.


The author continues to focus on removing the insured patient from the middle of the reimbursement dispute when the patient receives services from an in network hospital or other facility and receives a "surprise" bill from a physician who also provides services and is not contracted to that plan or is out of network.


The current version of AB 533 would prohibit the out of network physician from charging or collecting from the patient any more than their co-insurance and deductible under their policy. It would prohibit balance billing and require the plan to reimburse that physician/group at the plan's "average contracted rate". Those plan rates would be confidential and not subject to disclosure or review. If the physician/group is unhappy with that reimbursement they would exhaust the plan's appeal process and then appeal to an Independent Dispute Resolution Process (IDRP) established by DMHC and Department of Insurance that would determine if additional payment is appropriate. Very few details currently in the bill on how that process would work.


AB 533 now would exempt hospital emergency services that are used to stabilize the patient, which would include some limited laboratory services. Providers remain unhappy with an interim payment rate that is determined by the plans and not subject to disclosure or review, an IDRP process that is undefined and not loser pays format, and the lack of any provisions in the bill that incentivize or require the plan to have an adequate network or contracts with hospital based physician groups. The fact that all the plans support the bill and all the providers oppose the bill is a good indication of a lack of balanced approach.


Assemblyman Bonta continues to commit to a balanced approach and dialogue with all stakeholders. The CSP will continue to push for a solution that does remove the patient from the dispute but also provides fair reimbursement to providers.




ICD-10 Transition -- CMS Issues Some
Additional Flexibility for Providers


CMS has previously announced the implementation of ICD-10 code set for all medical diagnoses and inpatient hospital procedures as of 10/1/15. On July 7th CMS issued an advisory on some additional flexibility for providers in claims auditing and quality reporting processes. Those include;


  • For a period of twelve months after ICD-10 implementation Medicare contractors will not deny physician Part B claims under either automated medical review or complex medical record review based solely on specificity of the ICD-10 code so long as the practitioner used a code from the right family. A claim would however still be denied if no valid ICD-10 code was used on the claim.
  • For quality reporting for the 2015 program year, Medicare clinical quality data review contractors will subject physicians under PQRS, Value Based Modifier (VBM), or Meaningful Use (MU) penalties during audits for failure to use the most specific ICD-10 so long as the code is from the correct family of codes. That exemption will also apply to other elements of these programs if the only error or problem relates to the specificity of the code.


Medi-Cal has also announced the mandatory use of ICD-10 codes on the same Oct. 1, 2015 timeline but we have yet to see any similar limitations on claim or audit issues.



CURES Sign-up Requirement for All Physicians
with a DEA License to Prescribe


All pathologists need to be aware of the new requirement that all physicians authorized to prescribe, order or furnish Schedule II, II , or IV controlled substances are required to register with the DOJ Controlled Substance Utilization Review and Evaluation System (CURES) by 1/1/16. Though most pathologists would not prescribe controlled substances you may still have a DEA license to do so. This is part of the effort to control appropriate use of opiates and allow prescribing physicians to check patient prescription activity.


There is an on-line application but the application must them also be notarized prior to submission. You can get information at http://www.mbc.ca.gov/Licenses/Prescribing/cures_notice.pdf.


The Medical Board of California has announced assistance to physicians to avoid the requirement for notarization as follows;


Physician should log on to DOJ CURES website at oag.ca.gov/cures-pdmp, in the fifth paragraph, click on "application form electronically", on that page click link for "practitioner".


Complete the online app and click "submit".


Print the PDMP application confirmation, two pages, then sign and date it.


Attach a copy of (1) your current MBC license, wallet card is fine, (2) Your current DEA registration, and (3) A current driver's license or other govt. ID


You can then bring these documents in person to an MBC district office during business hours 8-5 located at:

2005 Evergreen Street 
Suite 1200 
Sacramento, CA  95815 
Probation Office 
160 E. Via Verde 
Suite 230 
San Dimas, CA  91773 
Probation Office 
12750 Center Court Dr. S 
Suite 750 
Cerritos, CA  90703 

One you do this a confirmation will be emailed to you by DOJ. 




CSP 68th Annual Meeting
Now Available!

CSP 68th Annual Meeting schedule and registration is Now Available!


Join us at the Hyatt Regency San Francisco from December 1-5, 2015.


California Society of Pathologists
One Capitol Mall Suite 800
Sacramento, CA 95814 
Tel : 916-446-6001
Fax :  916-444-7462

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