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 »
Physicians apprehensive regarding requests for provider directory information The California Medical Association (CMA) continues to receive inquiries from practices concerned about the validity of requests for payors to confirm physician demographic information. The requests are related to the new provider directory accuracy law that took effect on July 1, 2016 (SB 137). Under the new law, physicians are required to respond to plan and insurer notifications regarding the accuracy of their provider directory information either by confirming the information is correct or by updating demographic information as appropriate. As with any request for protected information, practices should verify ... August 9, 2017 General Medical Provider Networks, Network Adequacy, Prov ider Directories, Provider Directory Accuracy Law, Provider Networks 0 0 Comment Read More »
CMA publishes FAQ on controversial new law to end "surprise billing" In September 2016, Governor Jerry Brown signed into law a controversial bill (AB 72) that will change the billing practices of non-participating physicians providing non-emergency care at in-network hospitals, ambulatory surgery centers and laboratories. While the enactment of AB 72 can never be described as favorable, the end result is a law that puts to rest the issue of so-called “surprise billing” in a way that preserves the ability of physicians to continue collecting their usual rate (as long as they obtain the consent of the patient), implements a statutory ... October 14, 2016 General, Managed Care Network Adequacy, Out of Network Care, Provider Networks 0 0 Comment Read More »
Will your practice be ready to comply with the requirements under new provider directory accuracy law? On July 1, 2016, a new law will take effect that requires plans to ensure that physician directories are accurate and up-to-date. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payors' networks. Plans and insurers will be required to have certain data fields in the directory including, but not limited to, provider name, specialty, board certification (if any), practice address, city, zip, license number, NPI, whether the provider is accepting new patients, the product ... April 14, 2016 General Payor Contracting, Provider Directories, Provider Networks, Network Adequacy 0 0 Comment Read More »
Health plan group pilots program to improve physician directories America's Health Insurance Plans (AHIP) is launching a pilot program to ensure that physician directories are more accurate and up-to-date, the organization announced last week. The pilot program involves two directory vendors, BetterDoctor and Availity, and will include providers in three states: California, Florida and Indiana. The pilot program will run from April to September, according to AHIP, and will include the following eight California plans: Anthem Blue Cross Blue Shield of California Health Net of California Humana ... April 4, 2016 Managed Care Insurance, Medical Provider Networks, Provider Networks, Health Plans 0 0 Comment Read More »
Final regulations requiring health insurers to have adequate networks and accurate directories go into effect The California Department of Insurance (CDI), which regulates most PPOs in the state, issued permanent regulations this week that require health insurers to develop and maintain adequate provider networks. This move comes after emergency regulations were issued in January 2015 to help ensure patients can get timely access to care. While the California Department of Managed Health Care (DMHC), which regulates HMOs and certain PPO products, has had in place network adequacy standards for a number of years, CDI has not. These regulations will thus ensure that Californians, regardless of ... March 31, 2016 Managed Care Medical Provider Networks, Network Adequacy, Provider Networks, Department of Insurance 0 0 Comment Read More »
CMA files amicus brief in case that could weaken physician protections from silent PPOs The California Medical Association (CMA) and nine other physician organizations filed an amicus brief asking the Supreme Court of California to review an appeals ruling that would have significant, widespread negative impact on the health care industry, undermining a California law designed to protect physicians from "silent PPOs." Robust managed health care provider networks and reasonable reimbursement for medical services are vital to ensuring adequate accessibility and the highest quality of medical care. A historical and ongoing threat to these goals is the silent PPO problem, whereby health plans unilaterally ... January 15, 2016 Managed Care Legal Advocacy, Payor Contracting, Provider Networks, Silent PPOs, Amicus Briefs 0 0 Comment Read More »
New law requiring accurate provider directories includes provider obligation to update information On July 1, 2016, a new law will take effect that requires plans and insurers to comply with uniform standards, and provide timely updates, for their provider directories. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payor’s network. Specifically, the law requires: Plans/insurers must offer an online provider directory available to the public, including physicians, without any restrictions or limitations. ... December 7, 2015 Managed Care Network Adequacy, Payor Contracting, Provider Networks, Commercial Payors 0 0 Comment Read More »
California State Auditor releases report outlining flaws with Medi-Cal program The California State Auditor’s office released a report on Tuesday expressing a need for better monitoring of the health plans participating in California’s Medicaid program, Medi-Cal, in order to improve beneficiaries’ access to care. Among the key findings of the audit was that the California Department of Health Care Services (DHCS), which administers Medi-Cal, “has not consistently monitored health plans to ensure that they meet beneficiaries’ medical needs—it did not perform any annual medical audits before 2012 and performed medical audits on less than half of the health plans in ... June 26, 2015 Medi-Cal DHCS, Medi-Cal, Network Adequacy, Provider Networks, Department of Health Care Services 0 0 Comment Read More »
United Healthcare amendment introduces narrow network product Setting the stage for its potential future entrance into California’s Exchange, Covered California, United Healthcare (UHC) has begun the process of building its provider networks by amending physician contracts. United Healthcare has advised CMA that its new Core plan, which will be marketed to employer groups seeking lower premiums and used for its potential future exchange product, will access a significantly narrowed network of approximately 45 percent of UHC’s current PPO provider network. UHC plans to send amendment notices to physicians selected to participate in the Core network sometime in ... February 4, 2015 Managed Care United Healthcare, Provider Networks 0 0 Comment Read More »
