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DMHC Finalizes Balance Billing; CMA Calls Regulation a Giveaway to HMOs at Expense of Physicians and Patients After several months of receiving and reviewing comments on its proposal, the Department of Managed Health Care (DMHC) last month finalized its balance billing regulation. The regulation defines “unfair billing patterns” to include the practice of balance billing patients for the unpaid balance of bills only partially paid by HMOs for noncontracted emergency services. While the DMHC describes the regulation as an attempt to “restrict the practice of balance billing,” DMHC has no statutory authority to enforce or promulgate such a regulation. This regulation must now go to the Office of Administrative Law (OAL), to review the regulation for necessity, authority, clarity, consistency, reference, and nonduplication. If OAL finds that the regulation does not meet these standards, it will be sent back

to DMHC to try to correct the deficiencies. If OAL approves the regulation, CMA will take legal action to stop it from being implemented. CMA has already assembled an outside legal team and is in the process of raising funds for the legal fight. After DMHC proposed this regulation in March, CMA organized physicians to appear at hearings around the state to voice our opposition to these physician-unfriendly and unlawful regulations. Additionally, CMA filed extensive comments explaining our opposition to the regulation and why we believe DMHC to be overstepping its authority. The issues raised in these comments will serve as the basis for much of the OAL review and for our legal opposition. Essentially, DMHC has used a law intended to protect physicians to promulgate

Blue Shield Clarifies Contract Amendment CMA has received a number of calls from physicians concerned about a new Blue Shield contract amendment that was issued in response to the California Department of Insurance’s new health care access regulations. CMA has been working with Blue Shield to clarify what this amendment means to physicians. Blue Shield has assured us that the amendment is not intended to create any new onerous obligations for physicians or interfere with the scope and level of services a physician provides in his or her practice. Blue Shield has also indicated the amendment’s nondiscrimination language, while not taken directly from the regulations, will be interpreted within the framework of applicable state and federal law. (Log on to www.calphys. org/html/cc744.asp for a formal clarification statement jointly developed by CMA and Blue Shield on this issue.) If you have any questions about the amendment or the clarification statement, contact Blue Shield Provider Services at 800/258-3091. CMA continues to have concerns about the regulations themselves and has taken several steps to address both the underlying regulations and implementation efforts by insurers. CMA is working with the DOI to obtain clarification with respect to the newly mandated language. Contact: CMA’s reimbursement help line, 888/401-5911 or (CMA Alert, August 18, 2008 issue)

a regulation that attempts to prevent physicians from getting fully paid for the services they provide. Unlike previous proposals on balance billing, this version does nothing to regulate or obligate HMOs in any manner – failing to address both fair payment of physicians and inadequate physician networks. This regulation is an attempt by the Schwarzenegger Administration to appear to be defending the interests of patients, when, in fact, it is simply a giveaway to HMOs at the expense of physicians and patients. CMA will continue to provide updates as OAL completes its review. Contact: Armand Feliciano, 916/444-5532 or (CMA Alert, August 4, 2008 issue)

CMA Legislative Victory – Physicians Removed From Costly and Burdensome Reporting Legislation In response to months of persistent lobbying by CMA and doctors in the author’s district, AB 2967 (Lieber), a bill which could impose unlimited data reporting requirements on health care providers, has been amended to exclude physicians and physician groups.   CMA has long supported efforts to improve medical outcomes, the stated intent of AB 2967. However, prior to being amended, the bill would have required physicians and physician groups to give to a newly created state agency as much patient data as the agency demanded. This new bureaucracy would be created despite the fact that the state already has a successful outcomes reporting program under the Office of Statewide Health Planning and Development.   By being excluded from AB 2967, physicians’ and physicians groups are also saved from paying the tens of millions of dollars in costs related to the legislation. Not only would they have been forced to pay for any additional staff necessary to collect and provide the data, physicians and physician groups would have been required to pay unlimited fees to fund the state agency. Intent language reflecting these concerns was also amended into the bill, so that any reporting requirements reflect an understanding of the financial burdens such requirements impose on physicians and physician groups. Contact: Lisa Folberg, 916/551-2880 or (CMA Alert, August 18, 2008 issue)

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2008 September/October  

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