September 28, 2017
Area(s) of Interest: Payor Issues and Reimbursement AB 72 Out of Network Billing
The California Medical Association (CMA) has published a new guide to help physicians challenge “interim payments” under the new AB 72 out-of-network billing and payment law. The guide is free and available exclusively to members in CMA’s AB 72 resource center.
On July 1, 2017, the new law (AB 72) took effect changing the billing practices of non-participating physicians providing covered, non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories.
The law requires plans and insurers to reimburse physicians at the greater of either the payor’s “average contracted rate” or 125 percent of the Medicare fee-for-service rate for the same or similar services in the general geographic region in which the services were rendered, unless otherwise agreed to by the noncontracting provider and the payor. However, it also includes mechanisms for physicians to challenge the interim payment if they believe it to be insufficient.
This new guide - “A Physician's Guide to the AB 72 Independent Dispute Resolution Process” - provides physicians a detailed look at the IDRP, an overview of the two regulators’ processes, how to determine eligibility, guidance on how to make your case for additional reimbursement, filing fees and general timelines.
In CMA’s AB 72 resource center you will also find a number of other resources to help physicians navigate this new system, including an FAQ, a sample appeal letter, a payment monitoring workbook and a series of on-demand webinars.
For more information, visit the Out-of-Network Billing page or call CMA’s Reimbursement Helpline at (888) 401-5911.