APS has been closely following the California Assembly Bill (Bonta) AB 72 since its introduction back in CY 2014. AB 72 will prohibit/ban balance billing any enrollee or insured for Out of Network (OON) physician charges provided in a contracted hospital/facility. Further, this bill would require the enrollee or insured to pay the non-contracting physician the same cost sharing required as if the services were provided by a contracted physician. This would be referred to as an “In-Network Cost-Sharing Amount.” This means an enrollee or insured will not owe any more than the in-network cost-sharing amount. It is important to point out that the interim payment amount for an Out Of Network physician is either the Average In-Network contracted rate or 125% of the Medicare Physician Fee Schedule (MPFS), whichever is greater. For any claims dispute, the Department of Managed Health Care (DMHC) has established an Independent Dispute Resolution Process (IDRP). This is where a Non-Contracting Individual Health Professional (Physician) can submit an appeal for additional payment based on “reasonable and customary” value of services rendered which excludes the enrollee or insured in the process.
Last week, the CA AB 72 passed both the Senate and Assembly and was presented to the Governor on Friday September 9, 2016 for review and approval. The California Society of Pathologists (CSP) feels that it is more than likely that the Governor will sign and that AB 72 rule will pass. According to Bob Ackerman, the CSP has moved to a neutral position on this ruling together with the California Medical Association (CMA). If AB 72 passes, the new law will take effect July 1, 2017.
It is important to know how this new rule (AB 72) will affect your practice. APS is closely working with its clients to determine the overall impact it will have on their practices. APS will continue to monitor and provide updates on this new ruling as they become available.
In working through the wide variety of billing arrangements, APS found payments that we had been missing.