Though CRS sponsored legislation, AB 2764 (Bonilla), was held in the Assembly Appropriations Committee we continue to work to get the major payers to cover DBT. Many groups have helped their patients file Independent Medical Review (IMR) requests with the Department of Managed Health Care if their plan denies payment for DBT claiming it is investigational/ experimental. The DMHC website shows some 351 IMRs reviewed for DBT with over 90 % of the decisions reversing the plan denial of coverage. Please continue to encourage or assist your patients file IMRs if you provide DBT.
 

The CRS continues to do outreach to major plans to encourage that they reconsider any policies that deny coverage for DBT.  We recently met with Blue Shield policy managers and will be meeting with Anthem Blue Cross this month. Our thanks to Dr. James Schlund and his colleagues at the Chico Breast Center for hosting the Blue Shield meeting and representatives of Hologic who have provided key information on studies and changes being made to cover DBT by other plans around the country.

AB 533 (Bonta), which would have banned balance billing and created a process for determining  interim payment rates for out of network physicians who provide services in contracted hospitals and other facilities, remains under active consideration in the last month of the Legislative session. A small workgroup of Assembly Democratic and Republican members have been trying to develop a solution and the vehicle is now AB 72 with Assemblyman Bonta as the author with a number of co-authors from both sides of the aisle.

 

AB 72 passed the Senate Health Committee at the end of June with some additional amendments still under discussion. 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. There is ongoing discussion on possible amendments to address the network adequacy requirements for plans that we believe contribute in large part to the out of network billing issue. The Legislature will adjourn for the year on August 31st. 
 

Lumbar Epidural Injections, 62311 - Widespread Service Specific Targeted Review Notification
Noridian is initiating a service specific targeted review for CPT code 62311, injection(s), of diagnostic or therapeutic substances. Read the complete update.