CMA sponsored legislation (AB 1455 - The Health Care Provider Bill of Rights) includes many protections against unfair payment practices by health plans and insurers. This series provides an overview of the important California laws that protect physicians, how to identify and effectively stop unfair payment practices and how CMA can help.
California law prohibits Knox Keene regulated health plans, their contracting medical groups/IPAs, Medi-Cal managed care plans and PPOs from engaging in various unfair payment practices. The effectiveness of these laws and implementing regulations depends upon physicians and their office staff. This document provides the information physicians need to monitor their account receivables to ensure that they have been paid properly and to report any violations.
Plans and their contracting medical groups/IPAs, along with insurers, must provide physicians with at least 45-business days’ notice of a material change to a contract and give physicians the right to terminate the contract prior to implementation if they do not agree to the proposed change. It is important that practices have a process in place to review how such changes may affect the practice.
Timeframes for claim submission vary by payor and product type, however state and federal laws set limits on the deadlines most payors may impose. This document provides an overview of California’s timely filing limitations so physicians can review their individual contracts to ensure they do not include timeframes that are greater than the minimum timeframe allowed by law.
State and federal laws require that most payors reimburse clean claims within specific timeframes. California law further requires fully insured health plans and insurers to pay interest on claims that are not paid within the required timeframe and imposes penalties if the interest isn’t paid automatically.
Practice revenue is lost when claims are underpaid, delayed, or inappropriately denied. When your practice learns that a claim has been denied or underpaid inappropriately, steps should be taken to appeal the claim in writing. To ensure your appeal is processed as a provider dispute under the law, it's important it clearly indicates that it is an appeal and is submitted within the required timeframes.
Payors deny or underpay claims for a variety of reasons. This document includes information on the more common types of denials and underpayments and a brief description of how to address and resolve the claim issues.
California law prohibits health plans, their contracting medical groups/IPAs, and insurers from engaging in various unfair payment practices. The effectiveness of these regulations depends upon physicians and their office staff taking the time to report any unfair payment practices or other violations. This document will help you identify the appropriate regulator by plan type and how to access the formal complaint process.