News and Information

Call for Data: Out-of-Network Underpayment and Rescission of Treatment Authorization

CMA is conducting this survey to gauge the impact of the recent ban on balance billing by the California Supreme Court and by the Department of Managed Health Care’s regulation defining balance billing as an “unfair billing pattern.” CMA also is gathering evidence concerning other, broader industry practices by health insurers to underpay for out-of-network services.

Please take the time to complete this form as completely as possible. The information will be used by CMA in its advocacy efforts and will not be used in a manner that reveals your identity. We will contact you if further information is needed or if we can use your assistance in our advocacy efforts.

NOTE: For more information, see CMA’s Balance Billing Toolkit.

Questions about the survey can be directed to CMA’s Legal Hotline at (800) 786-4CMA. This survey can be submitted online or in hardcopy form by fax to the CMA Legal Department at (916) 551-2885.

Thank you in advance for your assistance.

This data is being collected for the purposes of our advocacy before the government to demonstrate the impact of the ban on balance billing. No specific fee data will be shared with the general public, including members of the California Medical Association. Physicians are again reminded that the antitrust laws prohibit independently competing physicians from collectively deciding upon their fees.

I. GENERAL INFORMATION

Note: This survey, except with respect to questions 12 and 13, requests information about payment practices by Knox-Keene plans; that is, commercial HMOs, the medical groups or IPAs that HMOs contract with, and many Blue Cross and Blue Shield PPOs.

Name of physician/group:

Contact information for person filling out the form
Name:		Phone:
E-Mail		County:
Specialty:
Contact information for billing service (if applicable)
Name:		Phone:
E-Mail

II. PAYMENT PRACTICES

1. Down-Coding: Have you seen an increase in the frequency of down-coding by any Knox-Keene plan since October 15, 2008?

Yes
No

a.If yes, please indicate the name of the plan(s) engaging in down-coding more frequently since October 15, 2008, the CPT code category (e.g. E/M, surgical, etc) , and the estimated percentage of increase in down-coding you have seen:

Payor	CPT Code Category (e.g. E/M, surgical, etc.)	% Increase in Down-Coding

		%
		%
		%
		%
		%
Other (Specify):
		%

Questions 2-4 are for non-anesthesia emergency services only (for anesthesia emergency services, please go to Questions 5-7).

2. Initial Payment Practices: Provide data concerning initial payments made on bills before and after the balance billing ban took effect. Please list the top 10 most underpaid CPT codes for non-anasthesia emergency services.

		Initial Payment in $
Payor	CPT Code	(Pre-Oct. 15)	(Post-Oct. 15)

		$	$
		$	$
		$	$
		$	$
		$	$
Other ( Specify):
		$	$
		$	$
		$	$
		$	$
		$	$

3. Post-Appeal Payment Practices: If you utilized the payor’s internal dispute resolution process, whether formally or informally, to appeal an underpayment fornon-anasthesia emergency services, indicate any additional payment as a result.

		Post Appeal Payment in $
Payor	CPT Code	(Pre-Oct. 15)	(Post-Oct. 15)

		$	$
		$	$
		$	$
		$	$
		$	$
Other ( Specify):
		$	$
		$	$
		$	$
		$	$
		$	$

4. Average Percentage Underpaid : For each Knox-Keene plan your practice deals with, please calculate the average percentage of underpayment of billed charges that plan paid, after all non-legal efforts have been exhausted. (E.g., if a plan on average pays $60 of $100 billed charges, the average percentage of underpayment is 40%.)

	Average % of Billed Charges Underpaid
Payor	(Pre-Oct. 15)	(Post-Oct. 15)

	%	%
	%	%
	%	%
	%	%
	%	%
Other ( Specify):
	%	%
	%	%
	%	%
	%	%
	%	%

Questions 5-7 are for anesthesia emergency services only.

5. Initial Payments: Please list the top 10 CPT codes underpaid for anesthesia emergency services only.

		Conversion Factor Billed	Initial CF Payment in $
Payor	CPT Code	Conversion Factor Billed	(Pre-Oct. 15)	(Post-Oct. 15)

			$	$
			$	$
			$	$
			$	$
			$	$
Other ( Specify):
			$	$
			$	$
			$	$
			$	$
			$	$

6. Post-Appeals Payments : If you utilized the payor’s internal dispute resolution process to appeal the underpayment for anesthesia emergency services, please indicate any additional payment as a result.

		Post-Appeal CF Payment in $
Payor	CPT Code	(Pre-Oct. 15)	(Post-Oct. 15)

		$	$
		$	$
		$	$
		$	$
		$	$
Other ( Specify):
		$	$
		$	$
		$	$
		$	$
		$	$

7. Average Percentage of Billed Conversion Factor Disallowed: For each Knox-Keene plan your anesthesia practice deals with, please calculate the average percentage of the billed conversion factor that plan refused to allow, after all non-legal efforts have been exhausted.

	% of Billed CF Disallowed
Payor	(Pre-Oct. 15)	(Post-Oct. 15)

	%	%
	%	%
	%	%
	%	%
	%	%
Other ( Specify):
	%	%
	%	%
	%	%
	%	%
	%	%

III. OTHER NEGATIVE IMPACTS

8. Administrative Costs of Disputing Underpayments: Provide actual data or estimates of staff time/costs (e.g. time to prepare appeals, delays in payment, material costs to mail appeal, time to follow-up on appeals, time to post additional payment, if received).

Estimated dollar costs in disputing an underpayment by a Knox-Keene plan:

9. Contracting Practices : Describe any changes in contracting practices by any Knox-Keene plan since October 15, 2008 (e.g. whether proposed rates have decreased, negotiations have ended prematurely, or a payor has terminated a contract). Please be as specific as possible:

10. Impact on Quality of Care: Describe any impact on quality of care you have you seen since October 15, 2008 (e.g., inability of patients to find an appropriate network physician, less staffing at provider facilities, increased patient wait times to see a provider, difficulty securing on-call coverage).

IV. THE DMHC’S DISPUTE RESOLUTION PROCESS

11. Have you used the DMHC’s Independent Dispute Resolution Process?

Yes
No

(Forms and further information about this process are available at the DMHC’s website at http://www.hmohelp.ca.gov/providers/clm/idrpform.pdf .)

a. If yes, were you satisfied with the end result? If not, why? Please explain.

V. SYSTEMIC PAYOR PROBLEMS

12. Within the past three years, has any Knox-Keene plan or other health insurer (e.g., Blue Shield, United, Pacificare, Blue Cross, etc.) failed to pay for services (either in-network or out-of-network) you rendered after giving specific authorization for you to perform such services?

Yes
No

If yes, describe the circumstances, including identifying the plan(s) or insurer(s), the service(s) you performed (by CPT code) and the date(s) of service.

CPT:

Date(s):


b. Payor:		CPT:		Date(s):

13. Do you believe that any Knox-Keene plan or other health insurer (e.g., Blue Shield, United, Pacificare, Blue Cross, etc.), on a regular or recurring basis, has paid you for out-of-network services below what is reasonable in your market?

Yes
No

If yes, please identify the particular plan(s) or insurer(s) and explain why you believe it has paid you below-reasonable rates.


b. Other Payor:

14. If you have any other comments or information you'd like to provide, please do so below.

THANK YOU for participating in this CALL FOR DATA. Your help is important in our advocacy efforts.

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