For More Information WHAT YOU NEED TO KNOW BEFORE YOU FILE A COMPLAINT Which Plans Are Covered By the Unfair Payment Practices Law? Click here to visit the DMHC Provider Complaint Portal Fighting Payor Abuse An unfair payment practices action guide for physicians Payor Abuse Resource Center CMA's Unfair Payment Practices CD-ROM Available Free to Members [Posted 03/25/04]

The Department of Managed Health Care (DMHC) recently created an online complaint form that physicians can use to report violations of California’s unfair payment practices regulations by Knox-Keene licensed health plans.

Physicians can report individual incidents of payor abuse using the online complaint form, which is on the DMHC website. DMHC said data gathered will also be used to identify unfair payment trends engaged in by health plans and their capitated medical groups/IPAs. The form will accept complaints with dates of service on or after January 1, 2004.

The online tool is new. As with any new program, it may have glitches. CMA encourages physicians to use it and to tell us about any shortcomings so we may work with DMHC to improve the methods it uses to identify unfair health plan payment practices.

Although DMHC has thus far been slow to implement the CMA-sponsored unfair payment practices law, new DMHC Director Cindy Ehnes has said that under her watch enforcement of the regulations will be one of the department’s highest priorities. Without physician complaints, however, the regulations will be useless and nothing will change.

To file a complaint, go to http://www.dmhc.ca.gov/pcs. Print out each page of your complaint before clicking “submit” so that you have a copy for your records. After submitting the complaint form, you will receive an e-mail receipt confirming that the department received your complaint. This e-mail will also include your complaint number and a list of the supporting documentation DMHC needs to process the complaint. You will need to mail this documentation to DMHC. Make sure you include the complaint number on the documentation you submit to DMHC. 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. If you need help submitting a complaint form, contact CMA’s Reimbursement Help Line at 888/401-5911.

Click here for more information, including details on which claims are eligible for DMHC's individual claim review.

Contact: Aileen E. Wetzel, 916/444-5532 or awetzel@cmanet.org.