Balance Billing/ How is it impacting your practice
Earlier this year the California Supreme Court in the Prospect Medical Group case effectively eliminated the ability of a non-contracted hospital based radiologist from balance billing an enrollee of an HMO for emergency services. This means that such a patient could not be balance billed for example by a non-contracted radiology group for the CT scan that was provided to the patient during their visit to the hospital ER.
Though the impact is limited for hospital based radiology groups in terms of the total volume of services provided it is an inherently unfair policy that puts all the cards in the hands of the health plan or delegated medical group to determine what is "reasonable" reimbursement for the medical service. The Supreme Court did not decide what is "reasonable" but stated that the physician's recourse is with the plan and not the patient.
Radiologists who find themselves in this situation can look to the balance billing toolkit link on the CRS website at www.calrad.org .You can utilize the internal grievance procedure of the plan to appeal a low payment amount or file a claim to arbitrate the issue with the Department of Managed Health Care (DMHC) who has established a process to review such disputes. You can bundle similar claims and there is a minor fee to use this arbitration system.
We would like to know what radiology groups are seeing after the Prospect decision. Are plans offering contract terms that are less/more then the past? Are they using their out of network payment rates as there reimbursement mechanism for non-contract providers. Send us an email to Bob Achermann at bachermann@amgroup.us and tell us what is happening with your practice
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