October 24, 2016


Out of Network/ Balance Billing Signed By Governor/ Legal Challenge Filed

AB 72 (Bonta) was the final 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. It was clear that the Legislature wanted to pass a solution to this long standing issue.
 AB 72 as amended passed both the Senate and Assembly 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.  Health plans will also have to provide data to the regulators on their contracted rates and the process as to how they were developed. The CSP had moved to a neutral position on AB 72 and the CMA also changed their position to neutral prior to the floor votes.
Last week the Association of American Physicians and Surgeons, an Arizona based organization, filed suit in US District Court in California against the Governor and DMHC challenging the provisions of AB 72 and requesting injunctive relief to halt implementation. The suit alleged that the law violated the Constitution by improperly delegating authority to plans to set reimbursement rates for physicians who are not contracted. Typically, lawsuits requesting injunctive relief are heard quickly but since the laws does not take effect until July the Court could simply decide the case on its merits. We will monitor the case and keep you informed.

Bill Signed to Alter Cancer Registry Reporting

We are pleased to report that the Legislature has passed and the Governor signed AB 2325 by Assemblywoman Bonilla. AB 2325 would require that on or after January 1, 2019 that all pathologists diagnosing cancer will report those cancer diagnoses via electronic means to the California Cancer Registry (CCR). The bill resulted from a dialogue with the author who had an interest in clinical trials for cancer patients and the possible use of California Cancer Registry data to advance the goals of cancer treatment and outcomes.
In early 2015 representatives of the CSP began a dialogue with the CCR over the need for changes for cancer reporting. From those discussions came the creation of the California Data Modernization Consortium (CDMC), and our hopes for reforming the current reporting method to CCR. The CDMC includes representatives from the CSP, CAP, major EHR vendors, and the large health care systems. It was decided that though other details of the possible changes to the CCR would come from the deliberations of the CDMC that it was already clear that three things needed to change; (1) initial reporting of cancer diagnoses should come from the pathologist, (2) that reporting should be done in a standardized format, and (3) the report should be submitted electronically. There have been several pilots at select California hospitals using the CAP eCancer checklist and electronic reporting to CCR.
After introduction, AB 2325 was amended several times as it moved through the legislative process. The reporting will be required to use the College of American Pathologists cancer protocols data elements but the pathologist can submit in any electronic means directly from the Electronic Medical Record, or through a web portal provided by California Department of Public Health (CDPH). CDPH will prescribe the data to be submitted and will work with stakeholders to designate a standardized format for submission.
There were amendments to not penalize or make the pathologist responsible for missing or inaccessible patient demographic information that exceeded the required cancer-specific data elements. CDMC and its workgroups will be developing the specific patient identifier elements that should be provided in the reports.
AB 2325 was also amended to specifically indicate that a pathologist is not required to submit the same report more than once. In essence if a specific report is submitted electronically that CDPH can't require the same pathology report via a different means.
AB 2325 establishes the basic foundation that will help CCR to move towards its goal of near real-time identification and surveillance of cancer throughout the state.  It enables the governance structure and workgroups of CDMC to now build upon that framework of standardized data, electronic versus paper submission, and improved timeliness of reporting. It will allow the CCR to become a pioneer in the aggregation, management and clinical utility of cancer data.   The CSP is continuing to engage with the CDMC as it works to develop policies and enhancements over current CCR operations we can revisit the specifics of the statutes contained in AB 2325.

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California Society of Pathologists
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Sacramento, CA 95814 
Tel : 916-446-6001
Fax :  916-444-7462