CSP Challenges LA Care Health Plan on PCCP Payment Policy

March 25, 2022

On October 1, 2021, L.A. Care Health Plan sent out notices issuing clarification on source requirements for split-billed codes. L.A. Care determined that the fee schedule was specifically developed for reimbursement purposes only and not intended to be a billing guide or requirements document. As a result, L.A. Care stopped recognizing and paying for the Professional Component of Clinical Pathology (PCCP). As part of this new rule, L.A. Care clarified that certain pathology codes, specifically 80048 (Basic Metabolic Panel), 80100 (Qualitative Drug Screening), 85025 (Complete Blood Count) and others, would no longer be eligible for split billing. 

Bob Achermann, Executive Director of the California Society of Pathologists (CSP), has been involved since this issue first came to light. The CSP’s representatives have met with L.A. Care Health Plan agents multiple times to no avail. Recently, the CSP has retained outside counsel and sent a demand that L.A. Care Health Plan immediately cease and desist from continuing to apply this new Split Billing policy. The CSP also cited that by prohibiting the appropriate billing and reimbursement of pathology professional services, L.A. Care is in violation of its obligations to cover all services that would be available under the Medi-Cal Fee-For-Service.

APS will continue to monitor this situation.