California Physician

California’s new unfair payment practices regulations require Knox-Keene licensed health plans and their contracting medical groups/IPAs to resolve physician disputes in writing no more than 45 working days after receiving a physician dispute.

To ensure that disputes are resolved in a timely manner, CMA recommends that physicians document dispute submission dates and save dispute acknowledgements they receive from health plans. Proper documentation will enable DMHC to enforce the new regulations.

It is important for physicians to report unfair health plan payment practices to the Department of Managed Health Care (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 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, 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.