May 24, 2019
Update On Changes to Anthem Prudent Buyer Fee Schedule

We previously informed you that Anthem sent letters to providers under contract with the Anthem Blue Cross Prudent Buyer Plan announcing changes to their fee schedule effective 7/1/19. Though the letter indicates the changes are necessary to allow greater reimbursement for primary care and E & M services they don't indicate that many high volume anatomic pathology services are subject to significant reductions As much as 50-60%. The Prudent Buyer Plan has 8 geographic regions so the specific reimbursement amount can vary slightly but here are some examples of the impacted AP codes and how the proposed rates compare to Medi-Cal and Medicare payment rates;

Global rates Proposed Anthem Rate Medi-Cal Medicare
88305 $42.34 $40.99 $73.46
88307 $108 $87.64 $289.58
88341 $37.87 $60.62 $100.14
88342 $44.64 $53.79 $114.59
87480 $9.90 $18.03 $22.28

If you are a participating provider with Anthem Prudent Buyer Plan and have not received a letter and attached fee schedule you should contact the Network Relations Staff at CAContractSupport@Anthem.com. Here is a link to the fee schedule and you will find the pathology codes beginning on page 110.

The CSP is in contact with Anthem and the Department of Managed Health Care over the magnitude and impact of these proposed reductions. At this point we understand that Anthem Contract Managers have told some pathology groups that the issue is being reviewed. Others have been told that perhaps this fee schedule may not apply to their practice setting. We are still in discussion s with Anthem and have no clear guidance as of yet. We would encourage you to continue to reach out to Anthem to express your concerns.

We will update our members as we gather additional information.

CSP Supports Elimination of the Medi-Cal Provider Rate Cut

The CSP has continued to push both the Assembly and Senate Budget Sub-committees to request elimination of the 10% Medi-Cal Provider rate cut that has been in place since 2011. The cut began in the midst of the recession that caused a $25B shortfall in the State Budget. Some providers have now been exempted from the cut but relief to the physician community has been very narrow targeting only a handful of physician office visit codes and some pediatric services.
Last week the Assembly Budget Sub-Committee adopted a provision to eliminate the 10% Medi-Cal cut and that issue now will go to the Joint Conference Committee that will adopt a final version of the state budget to send to the Governor.
The Senate Budget sub-committee adopted a provision that eliminates that Medi-Cal pay no more than 80% of Medicare for laboratory services. Since Medi-Cal adjusted their rates previously based upon review of private payer rates it is no longer fair to additionally reduce rates based upon the 80% of Medicare methodology. In addition the pending PAMA implementation could further impact the applicable Medicare rate.
The budget must be adopted by June 15th so we will know the outcome in a few weeks.

CSP 72nd Annual Meeting - Save the Date!

December 3 - 7, 2019
Hyatt Regency San Francisco
5 Embarcadero Center, San Francisco, CA 94111


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