Assembly Health Committee Advances CMA Sponsored Prior Authorization Bill

A California Medical Association (CMA) bill to reduce prior authorization red tape has passed out of the Assembly Health Committee. This bill—SB 250 authored by Senator Richard Pan, M.D.—will allow physicians to spend less time on paperwork and billing and will allow patients to get the care they need without unnecessary delays.
SB 250 would require health plans to exempt physicians from prior authorization rules if they have practiced within the plan’s criteria 80% of the time. All other physicians will have the right under the bill for a prior authorization appeal to be conducted by a physician in the same or similar specialty.

“Insurance company prior authorization red tape creates serious and dangerous delays in care for many California patients,” says CMA President Robert E. Wailes, M.D. “We thank the Assembly Health Committee for passing SB 250 and bringing us one step closer to streamlining prior authorization requirements and minimizing delays or disruptions so that patients get the care they need when they need it.”

The bill now heads to the Assembly Appropriations Committee.

Share Your Prior Authorization Stories
CMA is asking you to share your unique experience as a patient, physician or health care professional so that we can demonstrate to lawmakers how prior authorization policies are harming patients.

If you have waited days or months for an insurance company to approve a medicine prescribed by your doctor, we want to hear from you. If you are a physician frustrated with the administrative headaches and their impact on your patient, we want to know your story.

CMA asks CIGNA to rescind burdensome modifier 25 policy

The California Medical Association (CMA) is urging Cigna to rescind its recently announced policy that would require the submission of medical records with all Evaluation and Management (E/M) claims with CPT 99212-99215 and modifier 25 when a minor procedure is billed. This change effectively penalizes physicians for providing efficient, unscheduled care to Cigna enrollees.
Cigna’s policy change would result in significant, unnecessary administrative burden and compliance cost to physician practices, would disincentivize physicians from providing unscheduled services and would create duplicate requests thus wasting health care dollars. The policy also lacks clarity on product types impacted, is inconsistent with industry standards and CMS guidance, and appears to violate California law.

CMA recently sent a letter outlining these concerns in detail and has asked the payor to rescind the policy before the August 13, 2022, effective date.

The new Cigna policy is overly broad, requiring all physicians billing for office visit codes 99212-99215 with modifier -25 and a minor procedure code to submit medical records as a precondition for payment. This creates yet another unnecessary administrative burden on physicians that are using the modifier appropriately.

CMA believes a more collaborative approach to identify alternative methodologies for cost containment—including provider education on proper coding practices that do not bluntly penalize physicians using the modifier appropriately—will prove more effective and less costly in the long term.

Practices with questions regarding this policy update can contact Cigna Customer Service at (800) 88Cigna

(882-4462).

Cigna to reevaluate burdensome modifier 25 policy
CMA has learned that Cigna will delay implementation of its recently announced policy to require the submission of medical records with all Evaluation and Management claims with CPT 99212-99215 and modifier 25 when a minor procedure is billed. CMA had serious concerns with Cigna’s policy change as it would result in significant, unnecessary administrative burden.

CMA had serious concerns with Cigna’s policy change as it would result in significant, unnecessary administrative burden and compliance cost to physician practices, would disincentivize physicians from providing unscheduled services and would create duplicate requests thus wasting health care dollars. The policy also lacks clarity on product types impacted, is inconsistent with industry standards and CMS guidance, and appears to violate California law.

CMA and the American Medical Association reached out to Cigna regarding these serious concerns and urged the payor to rescind the policy. Due to this advocacy, Cigna has delayed implementation and the policy is under additional review. The reimbursement policy update therefore will not go into effect on August 13, 2022, as originally scheduled.

CMA believes a more collaborative approach to identify alternative methodologies for cost containment—including provider education on proper coding practices that do not bluntly penalize physicians using the modifier appropriately—will prove more effective and less costly in the long term. We will continue to work with Cigna to address our concerns and will provide updates as more information becomes available.

CMA urges CA Supreme Court to review ruling that could destabilize the health care marketplace
CMA recently submitted an amicus curiae letter with the California Supreme Court in support of a petition for review of an appellate court decision that if allowed to stand would create a significant gap in managed care regulation that ultimately could destabilize the health care marketplace.
In this case, County of Santa Clara v. Doctors Medical Center of Modesto, et al., an appeals court ruled that Santa Clara County—through Valley Health Plan its county-based Knox-Keene licensed health plan—is immune from common law reimbursement claims under public entity immunity in the Government Code.
While Santa Clara County is required to reimburse emergency services at the “usual, customary and reasonable” (UCR) amount under the California Health & Safety Code, the appeals court determined Santa Clara County is vested with discretion to determine the UCR amount.
The appellate court’s opinion insulates Valley Health Plan from civil liability for violating the Knox-Keene Act’s requirement for reasonable reimbursement for emergency care.
The ruling unjustifiably eliminates any accountability or responsibility of county health plans to fairly reimburse providers of emergency care. The disruption and uncertainty that will result if this ruling is allowed to stand could also impair patients’ access to care as more providers abandon the managed care market.
This ruling would disproportionately affect the neediest patients, as 95% of county-based health plan enrollment is Medi-Cal beneficiaries participating in Medi-Cal managed care. This is an underserved population that cannot afford to pay out-of-pocket for medically necessary services.
“There is no material distinction between Knox-Keene plans offered by a county, like Valley Health Plan, and those offered by commercial corporations. All licensed, full-service health plans must be subject to the same requirements under the Knox-Keene Act,” the CMA letter said. “To allow otherwise would create a patchwork of provider networks and service levels. That sort of uncertainty would threaten the financial viability of the managed care system, to the detriment of patients.”

CMA board chair issues statement in support of Prop. 1 to enshrine the right to reproductive freedom in CA
Shannon Udovic-Constant, M.D., Chair of the CMA Board of Trustees, issued a statement in support of California’s Proposition 1.
“The California Medical Association (CMA), representing the physicians of California, is proud to support Proposition 1, which will place a constitutional amendment on the November ballot to enshrine an individual’s right to reproductive freedom.
California has a long history of protecting and defending reproductive health care rights, and by reaffirming our basic and fundamental principle that women should be able to get the health care they need, our state is once again leading the way.
CMA strongly believes that medical decisions – including those around abortion and contraception – should be made by patients in consultation with their health care providers.
Passage of Proposition 1 will send the strongest possible message that reproductive freedom is a fundamental human right that will be protected in California with the fullest force of the law.”

Letter from CMA President
Dear CMA member,
On June 24, the U.S. Supreme Court overturned nearly a half century of precedent protecting patients’ rights to critical reproductive health care. While we had expected the decision, it did not lessen the blow.
The decision in Dobbs v. Jackson Women’s Health Organization is a direct assault on the practice of medicine and the patient-physician relationship and represents a dangerous intrusion of government into the medical examination room.
In response to the decision, California leaders worked quickly by placing Proposition 1 on the November 2022 ballot to explicitly enshrine the right to abortion and contraception in the state constitution through a vote of the people.
The California Medical Association (CMA) Board of Trustees voted to support Proposition 1 and we are a leading proponent of the initiative.
While abortion remains legal in California, one of the many difficult impacts of the Dobbs decision is the uncertainty and confusion it has created, even here in our state. California remains a sanctuary for people seeking abortion care and we are already seeing an influx of patients from states with abortion bans seeking care here. Additionally, there are now many states where medical residents cannot receive training in abortion care. CMA intends to be at the table to help answer questions around training out-of-state residents and how California physicians can help care for patients from states with abortion bans if those patients travel to California.
Fortunately, California has already begun to expand its abortion network to ensure equitable access to abortion services and protect reproductive health care providers. California started preparing for this possibility before the Dobbs decision was issued. CMA was proud to participate in the Future of Abortion Council and to support measures that came out of that work, including:

• AB 1242 (Bauer-Kahan, Bonta and Garcia) to create a comprehensive framework of civil and criminal protections to protect abortion providers and patients seeking abortion care
• AB 2626 (Calderon) to ensure abortion providers can obtain professional liability coverage
• AB 1918 (Petrie-Norris) to create a California Reproductive Service Corps in the Department of Health Care Access and Information, meant to recruit, train and retain more reproductive health providers

Additionally, CMA supported a $200 million investment into reproductive health, access and justice in the 2022-23 state budget, including:

• Over $40 million to increase the reproductive health care workforce, including scholarships and loan repayments for health care providers that commit to providing reproductive health care services
• $40 million to reimburse health care providers for uncompensated care provided to low- and moderate-income individuals who do not have health care coverage for abortion services
• $20 million for targeted recruitment and retention resources and training programs for health care providers who serve patients at a facility that provides reproductive health care

As California’s physicians, our voice is very important in this fight. And we have heard from many CMA members who stand committed to protecting the fundamental human right to access reproductive health services and ending this governmental interference in the practice of medicine.
CMA has long advocated for unencumbered access to reproductive health services and strongly believes that all personal medical decisions—including those around abortion—should be made by patients in consultation with their health care providers. In addition to continuing this advocacy, we are also working to develop resources that will help physicians understand and navigate the aftermath of the Dobbs decision.
Stay tuned in the coming weeks for more information, including what you can do to support your physician colleagues across the country who are grappling with the realities of the Dobbs decision. In the meantime, if you have questions, please feel free to reach out to our CMA member service center at (800) 786-4262 or email memberservice@cmadocs.org.
Best wishes for a healthy future,
Robert E. Wailes, M.D.
President, California Medical Association

Urgent Survey: CMA needs your help to advocate for better Medicare payments

Since 2001, inflation has increased by 40%, yet physician Medicare payments have only increased by 7%. Today’s Medicare payments on average lag 40% behind the cost of providing care. While hospital and nursing home payments are indexed to inflation (and as a result have increased by 60% since 2001), the broken physician payment system has burdened physicians with an uphill fight just to stop statutory and budget neutrality payment cuts year after year.

The California Medical Association (CMA) and the American Medical Association (AMA) are launching a major advocacy campaign in Congress to reform the Medicare physician payment system by implementing an annual inflation adjustment. You can help us be more effective in our advocacy efforts by taking this brief 3-minute survey about the status of your practice and access to care in your community. Click here to take the survey by August 2.