CA-AB533 (Out of Network Coverage)

We are not out of the woods yet regarding the controversial AB-533 which was introduced/proposed by California Assembly Health Committee Chair Rob Bonta but failed last year. AB-533 is an attempt to supposedly address the problems associated with patients receiving a “surprise bill” from an Out Of Network (OON) provider in a contracted facility. To simplify, the current version of AB533 will prohibit the OON providers (physician) from charging and collecting from the patient any more than their co-insurance and/or deductible under their insurance policy. Additionally, the physician reimbursement will be based on Medicare rates for OON at contracted facilities. This will require Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to separately establish a mandatory Independent Dispute Resolution Process (IDRP).

Providers remain very skeptical and unhappy with a temporary payment rate under the IDRP. APS continues to work with OON patient balances through claims appeals and other payment resolutions that are affordable as well as feasible for our clients. Additionally, the California Society of Pathologists (CSP) continues to work with the California Medical Association (CMA) on a temporary payment solution that uses the Fair Health Payment Database rather than Medicare as a default or as the temporary payment rates. APS Medical Billing will continue to monitor and provide more information as it becomes available.

References:
California Legislative Information. (2015). AB-533 health care coverage:  Out-of-network
Coverage.  Retrieved from https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB533

California Society of Pathologists. (2016). Out of network billing legislation. Retrieved from
http://archive.constantcontact.com/fs158/1101989185125/archive/1123587619365.html