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- California Pathologists, CAP Amend Prior Authorization ‘Gold Card’ Legislation
On August 2, the California Society of Pathologists (CSP) and the CAP in partnership with the California Medical Association (CMA) successfully amended Senate Bill 250 to include a payment safeguard to protect against adverse claims impacts on pathologists and patients.
The groups inserted an amendment mirroring the CAP’s statutory payment safeguard language, previously advocated for, and included in the AMA’s model prior authorization reform legislation. The CAP has been actively engaged as states pursue “gold cards” which exempt qualified providers from prior authorization requirements for select services who have previously demonstrated high performance and adherence to evidence-based medicine.
The California legislation prohibits health care plans and insurers from requiring prior authorization from contracted health professionals for services if it would have been approved no less than 90% of the prior authorization tests in the most recent annual contracted period.
The legislation failed in the 2022 session and will likely be reintroduced next year with CAP’s-CSP’s-CMA’s amendments. The CAP continues to monitor state proposals to ensure pathologists and clinical laboratories are not subject to denials and reductions of payment because of whether the qualified provider failed to use a laboratory benefit management program, or otherwise availed a waiver for prior authorization in the ordering of the laboratory service.