Earlier this week, CSP sent a demand letter to LA Care over their change in policy on the recognition of the Professional Component -26 modifier for reimbursement of clinical pathology services for their Medi-Cal patients.

In October, LA Care, one of the largest Medi-Cal Managed Care Organizations, issued a notice indicating that they would no longer recognize the -26 modifier on clinical pathology for reimbursement. CSP had two meetings with LA Care objecting to this change and indicating that Medi-Cal policy clearly recognizes reimbursement for hospital based pathologists and further that Medi-Cal policy on payment to hospitals usually excludes any reimbursement for the professional component for pathologists services.

Despite this strong policy support LA Care had informed the CSP that they would consider the information but would not make any changes to their announcement for now. Pathology groups had begun to experience denials from LA Care beginning in January.

CSP engaged outside counsel and sent a demand letter to LA Care requesting them to reverse the new policy. The letter again provided the existing Medi-Cal Fee For Service policy, the general exemption of physician professional fee from Medi-Cal hospital APR-DRG program, and the recognition in CPT of the professional component modifier for pathology services.

LA Care has acknowledged receipt of our demand letter and that they will respond after review.