California Physician

California’s unfair payment practices regulations require that Knox-Keene licensed health plans and their contracting medical groups/IPAs maintain fair, fast, and cost-effective payment dispute mechanisms for contracting and noncontracting physicians. Every time a health plan contests, adjusts, or denies a physician claim, it must inform the physician of the availability of the plan’s dispute mechanism and explain the procedures for filing a dispute.

Physicians are encouraged to carefully review their explanation-of-benefit forms (EOBs) to ensure that any claim that is contested, adjusted, or denied contains the required dispute mechanism notice and clear instructions on how to file a dispute.

It is important for physicians to report unfair health plan payment practices to DMHC, so the department can take action against plans (and their contracting medical groups/IPAs) that fail to comply with the new 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 prior to submitting a complaint to get help with filing the appropriate forms and supporting documentation to substantiate the unfair payment practice. 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.