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California balance billing ban challenged in court

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California Medical Association
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California physicians were already up in arms about the new ban on balance billing before it even went into effect. So it's little wonder that they have wasted no time in challenging the ban in court.

Doctors in California feel they shouldn't be punished for the HMO's stinginess, and wonder why the DMHC doesn't go after the HMOs and make them pay more, rather than prohibiting doctors from balance billing to try to make ends meet.

As Francisco J. Silva, the general counsel to the California Medical Association, points out, the job of regulators is to protect Californians from HMO's tendencies to underpay. What the CMA is objecting to (and trying to fight) is how the Department of Managed Health Care (DMHC) goes about that. The DMHC, for its part, says it is confident that its regulations will withstand these challenges.

To learn more about the dispute:
- read this AMNews piece

Related Articles:
California bans balance billing
CA providers, officials fight over balance billing
Schwarzenegger orders end to balance billing
CA sues Prime Healthcare for balance-billing insured patients

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As a medical coding educator and consultant, I preform audits of submitted claims to third-party payors for medical offices and clinics who are looking to increase their reimbursement. The first item I ask for is a copy of the facilities superbill (also called an encounter form or charge ticket) and I have yet to see a superbill free of errors. The superbill is a very poor way to code an encounter especially since most facilites employ billers. If the facility employs a certified coder, the superbill is updated as often as the insurance companies update and the submitted claims will match and be paid. If a claim is denied or downcoded a biller will usually re-submit the claim without changes whereas a coder will re-submit with documented proof from the medical record and coding standards and guildlines which leads to justified payment.
Therefore, although medical facilities deserve timely and accurate reimbursement, is it fair to ask the HMO et al to pay without first assuring the claims sent are accurate? Sending accurate claims is the facililtes responsibility --fix your internal billing procedures now before the ICD-10 puts you out of business in 2011.

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