BILL ANALYSIS �
SB 146
Page 1
Date of Hearing: June 12, 2013
ASSEMBLY COMMITTEE ON INSURANCE
Henry T. Perea, Chair
SB 146 (Lara) - As Amended: March 6, 2013
SENATE VOTE : 32-0
SUBJECT : Workers' compensation: pharmacy claims
SUMMARY : Repeals the requirement that a copy of a prescription
is a necessary element of a claim for reimbursement for a
medication provided to an injured worker. Specifically, this
bill :
1)Provides that a copy of a prescription for pharmaceutical
services is not necessary unless required under a written
agreement between an employer, insurer, or third-party claims
administrator and a pharmacy.
2)Allows an employer insurer, or third-party claims
administrator to request a copy of the prescription during a
review of any records of prescription drugs dispensed by a
pharmacy.
3)Provides that any entity that submitted a pharmacy bill for
payment on or after January 1, 2013, and was denied payment
for not including a copy of the prescription from the treating
physician, shall have 90 days after January 1, 2014, to
resubmit those bills for payment.
EXISTING LAW :
1)Establishes a workers' compensation system that provides
benefits to an employee who suffers from an injury or illness
that arises out of and in the course of employment,
irrespective of fault.
2)Provides that medical, surgical, chiropractic, acupuncture,
and hospital treatment, including nursing, medicines, medical
and surgical supplies, crutches, and apparatuses, including
orthotic and prosthetic devices and services, that is
reasonably required to cure or relieve the injured worker from
the effects of his or her injury shall be provided by the
employer.
SB 146
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3)Requires that any provider of medical services, including
pharmacies, must submit, as a condition required to obtain
payment for services or supplies provided, a request for
payment with an itemization of services provided and the
charge for each service, a copy of all reports showing the
services performed, the prescription or referral from the
primary treating physician if the services were performed by a
person other than the primary treating physician, and any
evidence of authorization for the services that may have been
received.
FISCAL EFFECT : Unknown.
COMMENTS :
1)Purpose . According to the author, the workers' compensation
reform enacted last year (SB 863 (De Leon), Statutes 2012,
Chapter 363) contained a provision that is unnecessary,
burdensome, and incompatible with the Division of Workers'
Compensation's (DWC) electronic billing standard for pharmacy
billings - which does not support attachments that would be
necessary to comply with the literal requirements of the new
statute (i.e., providing an actual copy of a prescription that
was issued electronically or telephonically). In the
administrative process implementing SB 863, pharmacy interests
sought a remedy to this problem, but the DWC (correctly)
concluded that the problem is statutory, and legislation is
required. This bill is designed to narrowly resolve this
problem.
2)Urgency clause . Proponents are seeking to amend the bill with
an urgency clause, and appropriate language is with the
Committee in Legislative Counsel form. However, it requires a
separate vote of the Committee to place the urgency clause
into the bill. Proponents have provided the Committee with
records indicating that legitimate pharmacy bills have been
denied based solely on the failure of the biller to comply
with the statutory requirement that is virtually impossible to
comply with.
3)Denied bills . The bill currently allows a 90-day period after
the bill would be effective (January 1, 2014) during which a
biller could re-submit a bill that was denied for failure to
comply with the specific requirement that the bill is
SB 146
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changing. This provision is necessary because SB 863 also
added a requirement that services be billed within a short
time frame after the services were rendered. If the Committee
agrees to adopt the urgency clause, the grace provision should
also be modified so that a biller could submit denied bills
immediately after the bill is signed, as opposed to having to
wait until January. The Committee has appropriate amendments
in Legislative Counsel form to accomplish this change.
4)Contractual agreements . Proponents have also agreed to add a
provision that would require a pharmacy biller to include a
copy of the prescription if it has entered into a contractual
arrangement with a payor to include the copy. The Committee
has appropriate amendments in Legislative Counsel form to
accomplish this change.
REGISTERED SUPPORT / OPPOSITION :
Support
CompPharma (source)
California Pharmacists Association
California Retailers Association
CVS/Caremark
Express Scripts Holding Company
Healthesystems
Modern Medical, Inc.
National Association of Chain Drug Stores
Pharmacy Management Services Inc. (PMSI)
Progressive Medical
StoneRiver Pharmacy Solutions
Opposition
None received.
Analysis Prepared by : Mark Rakich / INS. / (916) 319-2086