In a previous blog post, we talked about how patients are increasingly getting billed for surprise out of network physician services even when they are receiving care in an in network facility. In CA, the state legislature has pushed forward a bill that would make it illegal to do so. Instead, the provider would receive either 125% of the Medicare rate or the payer’s average contracted rate for the service, whichever is higher. The bill would also setup an independent dispute resolution process that would not include the patient if the provider does not agree w/the reimbursement.
I have some questions in my head around how this would be implemented from a payer’s perspective. Would this only apply to professional claims where the corresponding facility bill is in network? What would happen if the member chose to go to an out of network facility? Would those corresponding professional visits not be covered by this? Would claims adjudication systems need to be modified to account for this?