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CMA's
Unfair Payment Practices
To help physicians understand and benefit from the State of California’s new fair payment practices regulations, CMA has developed the interactive “Payor A B U S E M A T T E R S — R E A C T N O W ” CD-ROM. The CD is available free to members, and to nonmembers for $100. A printed version is available to members for $25 ($125 for nonmembers). The regulations are the result of the CMA-sponsored Unfair Payment Practices Law (AB 1455), which was passed by the Legislature in 2000 but didn’t become fully effective until January 1, 2004. The law prohibits Knox-Keene licensed-health plans (HMOs, Blue Cross PPO, and Blue Shield PPO) from engaging in unfair payment patterns and authorizes the California Department of Managed Health Care (DMHC) to fine and penalize plans that engage in such practices. Under the new regulations, health plans are required to, among other things, provide physicians with their complete fee schedules and payment rules, acknowledge receipt of all claims (whether or not they are complete), and resolve physician disputes within 45 days. The regulations also prohibit health plans from imposing unreasonable deadlines for claims submission and requesting medical records not reasonably relevant to the adjudication of a claim.
To order, select from the links above or call CMA’s publications line, 800/882-1262. Orders can also be placed through your county medical society. Click here for more details on the unfair payment practices prohibited under this law. Also see ON-CALL document #1051, “Physician Complaints/Unfair Payment Practices.” ON-CALL documents are free to members at CMA's members-only website. Nonmembers can purchase this and other ON-CALL documents for $2 per page at CMA's online bookstore. If you have any questions regarding unfair payment practices, please call CMA’s reimbursement help line at 888/401-5911.
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