Payor Abuse Rule #1: Fee Schedule Disclosure
[Posted 04/01/04]

Did you know that the State of California’s new unfair payment practices regulations require all Knox-Keene licensed health plans to fully and regularly disclose to contracting physicians their fee schedules and payment rules, including instructions for submitting claims and filing provider disputes?

Under the regulations, health plans were required to provide that information to contracting physicians on or before January 1, and the plans must continue to do so each year by the contract anniversary date. Health plans must also provide their complete fee schedules and payment rules in a timely manner to newly contracted physicians and must comply with all written physician requests for such information.

Under the new regulations, the California Department of Managed Health Care (DMHC) is authorized to penalize plans that fail to disclose their fee schedules or that engage in other unfair payment practices. It is important for physicians to report unfair health plan payment practices to DMHC, so that the department can identify and take action against plans that fail to comply with the new regulations. Click here to download a provider complaint form.

Please also fax a copy of your complaint to CMA’s Center for Economic Services at 916/551-2027. This is important so that CMA’s reimbursement specialists can monitor DMHC enforcement.

To help physicians understand and benefit from these regulations, CMA has developed the interactive “Payor Abuse Matters—React Now” CD-ROM. The CD is available to members free, and to nonmembers for $100. A printed version is available to members for $25 ($125 for nonmembers). To order, click here or call CMA’s publications line, 800/882-1262. Orders can also be placed through your county medical society.

For more information on unfair payment practices, see ON-CALL document #1051, “Physician Complaints/Unfair Payment Practices.”

Stay tuned to future issues for information on other unfair payment practices.

Contact: CMA’s reimbursement help line, 888/401-5911 or awetzel@cmanet.org.

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