California Physician

When a Knox-Keene licensed health plan denies, adjusts, or contests a physician claim, the plan must provide the physician with a detailed written explanation of why the action was taken.

Health plans (and their contracting medical groups/IPAs) must provide that explanation no later than 30 days after receipt of a PPO claim or 45 days for an HMO claim. Under the State of California’s new unfair payment practices regulations, the Department of Managed Health Care (DMHC) is authorized to penalize plans that fail to do so.

Physicians are encouraged to carefully review their Explanation of Benefit forms (EOBs) to ensure that their claims have not been improperly denied, adjusted, or contested, and that the explanations are clear and accurate. It is important for physicians to report unfair health plan payment practices to DMHC, so that the department can take action against plans that fail to comply with the new regulations. Click here to download a provider complaint form.

Please contact CMA’s Center for Economic Services at 888/401-5911 prior to filing a complaint to get help with completing the appropriate forms and including supporting documentation needed to substantiate the unfair payment practice to the DMHC.

Please also fax a copy of your complaint to CMA’s Center for Economic Services at 916/551-2027. This will allow CMA 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, contact your local county medical society or call CMA’s publications line, 800/882-1262. Order forms are also available online.

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.

Previous Payor Abuse Rules:

TO ORDER THE PAYOR ABUSE CD-ROM: Call your county medical society or CMA’s publications line, 800/882-1262.

TO REPORT AN UNFAIR PAYMENT PRACTICE or for help with other reimbursement related issues: Call CMA’s reimbursement help line, 888/401-5911, or e-mail awetzel@cmanet.org.