California Medical Association

Balance billing ban upheld

Dan Bowman — Thu, 04 Dec 2008 12:24:47 -0500

In yet another chapter in the ongoing saga of balance billing, a judge in Sacramento recently affirmed state regulations looking to protect consumers from the practice. Last month, physicians in California challenged the ban put on balance billing by the state, citing that doctor's shouldn't be punished for the stinginess of HMOs. Subsequently, Francisco J. Silva, the general counsel to the California Medical Association, wanted the California Department of Managed Health Care (DMHC) to go after HMOs, forcing them to pay more.

Still, Sacramento Superior Court Judge Michael P. Kenny, who "tentatively sided with the state" on the matter in November, upheld the department's regulations on Tuesday, even after hearing arguments from both the California Medical Association and the California Hospital Association.

Cindy Ehnes, director of the CDMHC, believes the ruling will help providers to get their money in a timely fashion, as well as protect consumers. "All along, the Governor and his Administration's goal has been to protect consumers from unfair and illegal balance billing," she said.

But don't expect the CMA to take the finding lying down; they more than likely will appeal the case.

For more on balance billing:
- check out the Sacramento Bee article

California balance billing ban challenged in court

Anne Zieger — Thu, 13 Nov 2008 10:06:24 -0500

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

CA court won't delay 10 percent Medicaid rate cut

Anne Zieger — Fri, 01 Aug 2008 11:34:47 -0400

A California state court has dashed the hopes of the state's providers, ruling that the state's new 10 percent cut in its Medicaid should move ahead. A group of powerful medical associations, including the California Medical Association and the California Hospital Association, had sought a preliminary injunction to stop the cut. In its ruling, the court found that even though the plaintiffs had shown that actual patient harm could result from the cut, federal law bars private parties from suing over rate cuts to Medi-Cal, as the state's Medicaid program is known.

Not everyone's been shot down, however. The California Pharmacists Association, which filed a separate suit, is also hoping to stop the rate cut. Meanwhile, the California Medical Association is considering filing an emergency appeal with an appellate court. Also, a state legislative committee has recommended shrinking the Medi-Cal cuts, though the recommendations wouldn't take effect unless the full legislature and governor pass a budget including those changes.

To learn more about this conflict:
- read this California Medical Association press release
- read this Modern Healthcare article (reg. req.)

Related Articles:
Study: OR Medicaid cuts push up ED visits
NY Medicaid losses may force big doctor training cuts
CA Medicaid payments to hospitals stalled

CA insurers spent less than 85 percent of revenue on care

Anne Zieger — Mon, 14 Jul 2008 11:00:08 -0400

A new report by the California Medical Association concludes that nine of the state's major health plans spent less than 85 percent of their revenue on medical care for their beneficiaries, a level which would become law if the state legislature passes a bill the CMA supports.

The CMA's medical spending report, which addresses the fiscal year ending June 30, 2007, uses data collected by the state's Department of Managed Health Care. Spending ranged from a low of 69.4 percent for Great-West Healthcare of California, to publicly-owned L.A. Care Health Plan, which spent 97.1 percent of revenue on care. Cigna weighed in at 94.3 percent, while WellPoint-owned Blue Cross of California came in at 79 percent. Kaiser Foundation Health Plan had a medical loss ratio of 90.6 percent.

By the CMA's calculations, if all of these plans had spent 85 percent of their revenue on care that year, it would have resulted in $1 billion more to pay providers, with the majority ($933 million) coming from California's two Blue plans.

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

Related Articles:
CA doctors say state health plans made $4.3B in profits
CA effort pushes insurers to spend more on care
CA aims to cap insurer profits
CA providers, carriers spar with patients over access