On July 1, 2017, a new law (AB 72) took effect that changes 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 was designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an out-of-network doctor. 

The new law requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for 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. However, it also includes mechanisms for physicians to challenge the interim payment.

To dispute the interim payment, physicians must first appeal to the plan/insurer. If the physician is unable to resolve the issue through the payor’s internal appeal process, the new law requires the Department of Managed Health Care (DMHC) and California Department of Insurance to establish an Independent Dispute Resolution Process (IDRP) by September 1, 2017. To view the California Medical Association’s (CMA)  comments to the DMHC on the IDRP, click here.

CMA has published a number of resources to help physicians navigate this new system, including a sample letter physicians can use to appeal to the plan/insurer and an FAQ. These resources are available free to members only in our AB 72 Resource Center at Out-of-network Billing.

CMA is also hosting a free members-only webinar on the different options for challenging the interim payment on September 27, 2017. The webinar will include an overview of the dispute options, details on how the IDRP will work and CMA resources available to assist physician members. Click here to register for the webinar.

If your practice has experienced a change in payor behavior regarding contract negotiations, claims payment or network adequacy concerns, or is experiencing other challenges, CMA wants to hear from you.

For more information, visit the Out-of-network Billing Resource Page or call our Reimbursement Helpline at (888) 401-5911.