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Payor Abuse Rule #2:
The State of California’s new unfair payment practices regulations require all Knox-Keene licensed health plans and their contracting medical groups/IPAs to notify contracted physicians in writing 45 days before instituting any changes to fee schedules and payment rules. The regulations authorize the California Department of Managed Health Care (DMHC) to penalize plans that fail to provide such notice. Any changes made without proper notification should be reported to DMHC and CMA. It is important for physicians to report unfair health plan payment practices so the DMHC can identify and take action against plans that fail to comply with the regulations. Provider complaint forms are available in the Unfair Payment Practices Resource Center. Please contact CMA’s Center for Economic Services at 888/401-5911 before filing a complaint so that our reimbursement specialists can guide you through the complaint-submission process and advise you on the supporting documentation DMHC will require to substantiate an unfair payment practice complaint. Please also fax a copy of your complete complaint to CMA’s Center for Economic Services at 916/551-2027. This will allow CMA reimbursement specialists to monitor DMHC enforcement. To further help physicians,
CMA has developed the interactive “Payor Abuse Matters—React
Now” CD-ROM. The CD is free to members ($100 for nonmembers). 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 For more information on unfair payment practices, 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 ON-CALL documents for $2 per page at CMA’s online bookstore. Contact: CMA’s reimbursement help line, 888/401-5911 or awetzel@cmanet.org. More Payor Abuse Rules:
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