Payors report system changes to comply with AB 72 When California’s new out-of-network billing and payment law (AB 72) took effect on July 1, 2017, the California Medical Association (CMA) began receiving calls from physician offices concerned that Anthem Blue Cross and Blue Shield of California were not correctly paying claims. In both cases the incorrect payments were linked to manual processing of AB 72 claims. CMA worked with Blue Shield to ensure affected claims through October of 2017 were automatically reprocessed. Blue Shield also committed to conducting weekly audits to catch any additional claims that were processed erroneously. ... April 5, 2018 General, Managed Care Anthem Blue Cross, Blue Shield, Economic Advocacy, AB 72, Out of Network Care 0 0 Comment Read More »
Anthem dials back modifier 25 payment reduction policy; delays implementation This past fall, Anthem Blue Cross notified physicians in several states that effective January 1, 2018, it would reduce reimbursement of evaluation and management (E&M) services billed with modifier 25 by 50 percent. The California Medical Association (CMA) quickly jumped into action and coordinated with the American Medical Association (AMA) and the American Association of Dermatologists, along with many other state and specialty organizations, to push back on the proposed change. Due to the overwhelming opposition from organized medicine, Anthem recently announced it would reduce the magnitude of its modifier ... January 29, 2018 General, Managed Care Contract Amendment, Economic Advocacy, Payor Contracting, Anthem Blue Cross 0 0 Comment Read More »
Are you being paid correctly under California's new out-of-network billing and payment law? Effective July 1, 2017, California’s new out-of-network billing and payment law (AB 72) requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for covered, non-emergent services performed at in-network health facilities, and places limitations on the ability of physicians in such circumstances to collect their full billed charges. The interim rate is the greater of the payor’s average contracted rate or 125 percent of the amount that Medicare reimburses on a fee-for-service basis for the same or similar services in that geographic region. This law ... January 29, 2018 CMA, General Economic Advocacy, AB 72, Medical Provider Networks, Out of Network Care, Provider Networks 0 0 Comment Read More »
Anthem still not complying with AB 72 interim payment rules, physicians report The California Medical Association (CMA) has continued to receive reports from physician offices that Anthem Blue Cross is not paying the “interim payment” as required under California’s new law (AB 72) limiting out-of-network billing for covered, non-emergent services performed at in-network facilities. CMA has also received reports that Anthem representatives have advised some physicians that its Covered California EPO products are not subject to AB 72, which is incorrect. The new law requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for non-emergent services performed ... December 28, 2017 Managed Care Anthem Blue Cross, AB 72, Economic Advocacy, Out of Network Care 0 0 Comment Read More »
CMA guide helps physicians challenge AB 72 interim payments The California Medical Association (CMA) has published a new guide to help physicians challenge “interim payments” under the new AB 72 out-of-network billing and payment law. The guide is free and available exclusively to members in CMA’s AB 72 resource center at www.cmanet.org/ab-72. On July 1, 2017, the new law (AB 72) took effect changing the billing practices of non-participating physicians providing covered, non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. The law requires plans and insurers to reimburse physicians at the greater of either the payor’s ... October 13, 2017 General, Managed Care AB 72, Economic Advocacy, Out of Network Care 0 0 Comment Read More »
Ask the expert: Making a business case to join a payor network When physicians identify a payor network they wish to join, typically their first step is to submit a letter of interest or intent signaling their desire to join. However, physicians often fail to adequately present a “business case” as to why the payor would want to add the practice into their network. Failure to present a business case often results in a quick reply from the payor indicating that they have no interest or need to add providers to their network at this time. To prevent the “auto-reply,” the ... April 19, 2017 General, Managed Care Economic Advocacy, Insurance/Reimbursement, Payor Contracting 0 0 Comment Read More »
