Insurance/ Plan Payment for Digital Breast Tomosynthesis
The CRS continues to push for coverage of DBT by private insurers.  Existing law requires insurers and plans to cover all screening and diagnostic mammography services ordered by a physician but almost all are denying coverage for DBT claiming it is investigational. Though our sponsored bill AB 2764 (Bonilla) stalled in the Assembly fiscal committee in recent weeks the following has occurred;
  • CRS has sent letters to both the Department of Managed Health Care and the Insurance Commissioner requesting that they require plans and insurers to cover DBT without patient cost sharing based upon federal law and the ACA.
  • CRS representatives met with the medical directors and contract staff for both Blue Shield and Anthem Blue Cross to urge them to alter their medical policies and cover DBT. We met with Anthem at the offices of DMHC and they indicated their concern with the high number of IMR requests by patients.
  • DMHC website shows 376 IMR decisions involving DBT and 93% of those decisions overturn the plan denials. DMHC stated that another 400 IMRs were in the pipeline for review.
  • CIGNA announced that effective Aug. 23, 2016 that they would cover and reimburse for DBT.   
We know that some groups are encouraging their patients to utilize the DMHC IMR process to appeal the denial of coverage. We suggest that all radiology groups who provide DBT continue to help their patients. DMHC is aware of the issue and recommends that any patient who is denied coverage of DBT by their plan can submit a simple one-page form requesting IMR review.
 
Since the denial is made by the plan on the basis that the procedure is "investigational" the patient can use the IMR process without having to appeal internally to the plan. Given the current 90% or greater denial rate for DBT by health plans as "investigational or experimental" we have the opportunity and should empower our patients to go straight to the Independent Medical Review process of the DMHC to obtain satisfaction at two levels.  First the denial will be overturned and second the cost of the entire process of review goes on the health plan. Some radiology providers are seeing plans reverse course and pay for the service once an IMR is filed.
 
The IMR process can bring the plans to awareness quickly if thousands arrive.  Each center should make a vow to Inform, Sign, Retain, and Send in a minimum of 100 IMRs each week.
 
The process of submitting on behalf of patients their IMRs for DBT.  Please proceed with:
  1. Informing patients at the Time of Service why we are standing with them on the fight against breast cancer by having them sign at the time of service, their authorization for IMR on the full expectation of a coming denial for DBT.
  2. Obtain signatures on the IMR form (DMHC website) from patient signature line and "authorization to assist" signature line.  Two signatures here.
  3. Retain their form in center on their behalf awaiting notification of denial of payment by their health plan
  4. Submit IMR to the DMHC upon receipt of denial on behalf of the patient
The four step process for each center would then be: Inform, Obtain signatures, Retain, Submit upon notification of denial. We have included a copy of an explanatory form being used by one radiology group to educate their patients. It might be useful as a template for what DBT providers can use with their patients.
 
Since the Department of Insurance (DOI) also regulates some heath care insurance policies they may have jurisdiction. DOI mostly regulates PPO products and on their website they also have an electronic means for either a patient for file an IMR or a provider to file a complaint over a lack of coverage. Please go to www.insurance.ca.gov and click the link for consumers. The insured's insurance ID card may indicate the type of insurance or the patient can ask their insurer who has jurisdiction over the policy.

Out of Network/ Balance Billing Legislation Sent to Governor
AB 72 (Bonta) is the new vehicle which would ban balance billing and create a process for determining interim payment rates for out of network physicians who provide services in contracted hospitals and other facilities. A small workgroup of Assembly Democratic and Republican members have been developing a compromise solution involving all stakeholders including physicians.
 
AB 72 as amended passed both the Senate and Assembly this week during the end of the Legislative Session with near unanimous votes in both Houses. The interim payment amount for an out of network physician is now the greater of 125% of Medicare or the average contracted rate of the plan. The bill continues to contain an IDRP process whereby a physician/group could appeal for a higher level of payment above the interim payment amount. The bill does include some provisions to address the network adequacy requirements for plans that we believe contribute in large part to the out of network billing issue. The law will not take effect until July 1, 2017 for any policy that is issued or renewed on or after that date. Both DMHC and DOI have to establish an IDRP process and there will be some stakeholder engagement on issues prior to that date. The CRS had moved to a neutral position on AB 72 and the CMA also changed their position to neutral prior to the floor votes. The Governor has 30 days to take action on AB 72 but we assume he will sign the bill. Once the law is signed we will provide more detail on the various provisions.  
 
CRS Needs Your Help
Dear Colleague, 

We appreciate your membership support for the CRS and recognition of the value CRS provides to all diagnostic radiologists and radiation oncologists. Although ACR provides exceptional advocacy at the federal level, CRS plays a crucial and albeit indispensable role at the state level on regulatory and legislative issues that have real impact on our specialties. For example, just in this current year:
  • CRS joined in a coalition to have DHCS/ Medi-Cal reverse a decision that would have effectively denied life-saving screening mammography to women between the ages of 40 and 50. The policy was announced and retracted within a matter of 10 days.
  • CRS successfully opposed legislation that would have limited out of network radiologists and radiation oncologists from balance billing providing an interim payment at Medicare rates. CRS remains engaged in finding an equitable solution that protects the patient.
  • CRS has sponsored a bill to require health plans and insurers to reimburse for digital breast tomosynthesis.
The CRS remains committed to advocate on behalf of you and the rest of our colleagues on these and other important issues.   However, over the past several years, the CRS has experienced a depletion of its reserves primarily due to declines in membership and unforeseen substantial losses from the traditional CRS Annual Meeting that now threaten the viability of the CRS and its ability to continue these important advocacy efforts on your behalf.  CRS leadership has a strategic plan in place to alleviate these financial woes including efforts to reduce expenses, increase membership, and explore new sources of revenue.  For example, as a part of this plan and as a means of reducing expenses, CRS will not hold its Annual Meeting this year in the fall as in years past but will instead pilot a joint program session at the LARS (Los Angeles Radiological Society) Midwinter Meeting in early 2017.
 
The CRS strategic plan will take time to implement but its advocacy efforts cannot wait. The CRS has an immediate and urgent need to replenish its reserves so that it can continue to advocate effectively on your behalf.  As such, CRS leadership has decided to take the unusual step of asking individual members and/or groups to make a ONE-TIME voluntary contribution to ensure the financial survival of the CRS. These funds will stabilize CRS finances in the short term so that it can continue its indispensable advocacy work while permitting the strategic plan to work and rebuild CRS reserves.

Please consider a voluntary contribution and may we suggest the following contribution levels for individuals or groups. Of course, any amount would be appreciated:

Individuals
Group/Corporate
$100-499 Supporter
$1000-2499 Bronze Sponsor
$500-999 Bronze Circle
$2500-4999 Silver Sponsor
$1000-4999 Silver Circle
$5000-9999 Gold Sponsor
$5000+ Gold Circle
$10,000+ Platinum Sponsor

Any contribution is deductible as a business expense. You can make a donation via credit card by clicking on this link to a PayPal account. The link is also on the CRS website at www.calrad.org. Checks can be sent payable to the CRS at 1 Capitol Mall, Ste. 800, Sacramento, CA 95814.

We will provide special recognition to all contributors and appreciate your consideration.  If you have any questions please do not hesitate to contact any of the CRS officers or the CRS Executive Director, Bob Achermann.

Thank you for your support of the CRS.

Sincerely,
 
Jinha Park, MD  . PhD     
President                                                              
 
Stephen Holtzman, MD
President-Elect 
 
Harvey Wolkov, MD, FACR, FACRO
Secretary
 
Mark Yeh, MD              
Treasurer                       
 
Janak Raval, MD, FACR
Past President