CalDerm and Colleagues to Rally Against Scheduled Blue Shield Modifier-25 Cut

Advocacy, California , Federal,

CalDerm, CMA, and other specialty societies are working together to persuade Blue Shield of California to pull back its planned 50% to cut reimbursement for E/M services reported by the same provider on the same day as a minor surgery (Modifier-25). In its April 29 notification, Blue Shield declared that as of July 14, it will “no longer reimburse for the practice component twice, once of the E/M service, and again for the global day code.”

The scheduled modifer-25 cut will impact the entire house of medicine and is similar to previous moves by Anthem and Cigna which CalDerm and a host of other state and national physician organizations successfully rallied against and averted. The current proposal from Blue Shield poses a particular threat to Dermatology where the identification, evaluation, or treatment of new skin abnormalities in the course of an unrelated office visit is commonplace. Modifier-25 helps to ensure that patients can receive timely and efficient care by allowing reimbursement for such services on the same day as an unrelated visit. 

This week, CMA made an initial contact with Blue Shield about the proposal and is convening call with the payer. CalDerm will be coordinating our advocacy efforts with CMA and other organizations, as we seek to educate the health plan about the value of letting physicians respond to various patient needs during a single visit.

NP clean-up bill problematic for title transparency language

SB 1451 (Ashby), now travelling through the State Senate, has emerged as this session’s awkward vehicle for pursuing greater transparency on the use of physician and specialty designations.  The omnibus “committee bill” for the Senate Business & Professions Committee includes language that prohibits non-physicians from using “MD,”,”DO,” or “any other terms indicating or implying” they might lead a “reasonable person” to assume they are licensed MD or DO. Much of this language is already coded in Section 2054 of the California Business and Professions code. However, the current version of the bill does not offer any protection to specialty designations as CalDerm has been pursuing, beginning with AB 765 (Wood) last year. 

Additionally, the bill removes many of the requirements for independent NP practice that were established by AB 890 in 2020. The bill would allow Nurse Practitioners seeking independent practice to credit three years of completed clinical work experience between 2018 and 2023, either in CA or out-of-state, toward the requisite three years or 4600 hours of a “transition to practice” program.  The bill also allows an independent NP to attest to the completion of a transition-to-practice program for an NP trainee, rather than just a physician. The attesting physician or independent NP would not need to specialize in the same clinical category as the applicant NP. Furthermore, the attesting physician or independent NP would not be allowed to report or comment on the NP applicant’s clinical performance during the program to the Board of Registered Nursing. Finally, the bill would prohibit an NP from informing a patient, either in English or Spanish, of their right to see a physician and surgeon instead of a nurse practitioner. 

 For the moment, CalDerm is maintaining a Oppose Unless Amended position on SB 1451, which we conveyed during the Sen Business and Professions Committee hearing. The challenge now is to persuade the author to strengthen the title transparency provisions while also stiffening the independent NP qualifications, in the context of a committee omnibus bill intended to clarify existing statute more than to establish new policy.

Other bills of interest: 

AB 2668 (Berman) – CalDerm is supporting this bill that would require plans to provide $750 in coverage for wigs for patients with the medical condition that led to hair loss. The bill is being held on the Assembly Appropriations suspense file.

SB 898 (Skinner) – CalDerm is supporting this bill requiring new trucks and busses sold in California to have UV-filter driver and passenger windows starting with the 2032 model year. Bill is on the Senate Floor.

SB 516 (Skinner) – CalDerm has been providing input on this two-year bill to streamline the prior authorization process. The bill stalled near the end of the legislative process last year and negotiations are expected to continue until the summer’s final session deadlines. 

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