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January 25, 2016    


Out of Network Billing Legislation
AB 533 (Bonta) introduced last year failed passage on the last day of session in 2015. As we reported last year the bill was only one aye vote short for passage and a number of members abstained. Reconsideration was granted so that the bill could be taken up again on the Assembly Floor when the Legislature reconvened in January.

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 comparable Medicare rate.

AB 533 would exempt hospital emergency services that are used to stabilize the patient. Providers remain unhappy with an interim payment rate would use an Independent Dispute Resolution Process (IDRP) that is undefined and not loser pays format. The bill lacks any provisions to incentivize or require the plan to have an adequate network or contracts with hospital based physician groups.

Assemblyman Bonta convened a meeting of the stakeholders this week to indicate his hope to find an acceptable compromise through discussions in the short term. The CSP continues to work with the CMA and other specialty societies on an interim payment solution that uses the Fair Health Payment Database rather than Medicare rates as a default or interim payment rate. Physicians may seek to introduce a competing legislative proposal that is more equitable
Medi-Cal Expands Coverage for HPV Screening

The Medi-Cal program recently announced that they will now cover HPV testing retroactive to 10/1/15. Though not stated the policy basically follows the USPSTF recommendations to cover HPV co-testing with a pap smear once every 5 years for woman between 30 and 65 years of age. We have pasted below a copy of the announcement. Note that if you need to provide an HPV test outside the coverage parameters that a TAR would need to be obtained.

We are aware that there have been early claims processing issues;
  •  Xerox has been denying some of the claims for 87264 indicating that the claim must be billed using a modifier with a denial code 407. There is no need to bill with a modifier and that has been an error in their claims processing system. We are told that it has been fixed but you should look for those denials. 
  • There have been questions about the need to bill for the HPV test with a pap smear. That is not necessary but providers should maintain evidence in their records that the HPV was performed with the pap smear, i.e. co-testing.
Updated Age and Frequency Restrictions
for HPV Testing Codes
January 5, 2016
Effective for dates of service on or after October 1, 2015, human papillomavirus (HPV) testing codes 87624 (human papillomavirus, high-risk types) and 87625 (human papillomavirus, types 16 and 18 only, includes type 45, if performed) are reimbursable once every five years for recipients 30 through 65 years of age.

A Treatment Authorization Request (TAR) is required when billing HPV testing:
    • For recipients under 30 years of age
    • For recipients over 65 years of age
    • For testing frequency greater than once every five years.


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

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