December 14, 2017
Area(s) of Interest: AB 72 Advocacy Payor Issues and Reimbursement
The California Medical Association (CMA) has continued to receive reports from physician offices that Anthem Blue Cross is not paying the “interim payment” as required under California’s new law (AB 72) limiting out-of-network billing for covered, non-emergent services performed at in-network facilities. CMA has also received reports that Anthem representatives have advised some physicians that its Covered California EPO products are not subject to AB 72, which is incorrect.
The new law requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for 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 defined in AB 72 is the greater of the average contracted rate (including only commercial contracts) 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.
If your practice has received incorrect payments or denied claims from Anthem or any other payor related to the new law, CMA wants to hear from you. Practices can contact CMA at (888) 401-5911 or firstname.lastname@example.org.
For more information, visit our Out of Network Billing page.