May 3, 2019
Major Changes to Anthem Prudent Buyer Fee Schedule

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. In light of AB 72 on out of network physicians and a methodology for reimbursement this type of action by a major health plan will only exacerbate the prospect of pathology groups not agreeing to contract. That bill also requires monitoring of plan network adequacy.
We will update our members as we gather additional information.

CSP Supports Elimination of the Medi-Cal Provider Rate Cut

The CSP has presented testimony to 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.
The state budget picture has changed dramatically with an estimate of a surplus in the current fiscal year of $20B. The cut was not enacted based upon an assessment that Medi-Cal rates were too high but was a byproduct of desperate fiscal times for the overall budget.
In addition to the budget discussion we have also supported AB 719 (Diep) that would also repeal the cut for all providers. That bill passed the Assembly Health Committee on a unanimous vote.
The state budget must be approved by June 15th so we will know shortly whether we are successful in repealing this cut.

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