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Blue Shield corrects two problems affecting accurate payment of claims subject to new law

November 20, 2017
Area(s) of Interest: AB 72 Commercial Payors Payor Issues and Reimbursement Practice Management 


AB 72, California’s new out-of-network billing and payment law, requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for covered, non-emergent services performed at in-network health facilities, and places limitations on the ability of physicians in such circumstances to collect their full billed charges.


The interim rate is defined as the greater of the average contracted rate or 125 percent of the amount that Medicare reimburses on a fee-for-service basis for the same or similar services in the geographic region in which the services were rendered.


The new law also requires payors to honor assignment of benefits and issue the interim payment directly to physicians.


However, the California Medical Association (CMA) recently began receiving calls from physician offices reporting that Blue Shield of California was not paying the correct interim rate  and wasn’t paying the physician directly; instead, it was issuing payment to the patient.


CMA reached out to Blue Shield regarding the reports and has learned that both issues were due to manual claims processing errors. In some cases, the processors were not picking up the total units billed on the claim to accurately pay the correct interim payment, while in other cases, processors were also not issuing payment directly to the physician.


Blue Shield reports approximately 8,000 claims processed between July 1 and October 31, 2017, from about 1,000 different providers were impacted. Blue Shield is automatically reprocessing the affected claims. The reprocessing project is expected to be completed within four weeks.


While physicians do not need to submit appeals, CMA encourages creating a reference list of all affected claims to ensure that all claims are eventually paid correctly.


Practices with additional questions or concerns can contact CMA’s Reimbursement Helpline at (800) 786-4262 or economicservices@cmadocs.org.

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