In late May, the California Department of Managed Health Care held public hearings requested by the California Medical Association, seeking public comment on its new balance billing rule proposal. If enacted, the rule would stop physicians from billing patients for emergency services that a health plan has not fully paid for.

The DMHC had not planned to hold any hearings and to close the public comment period after May 12, but CMA pressure convinced the agency that it would exclude the viewpoints of too many doctors impacted by the rule change. The agency held its public comment period open to May 14 and scheduled three hearings on May 14, 19 and 20, in Irvine, San Diego and Sacramento, respectively, after this issue went to press.

The agency's proposed rule change defines "unfair billing patterns" as billing a patient for amounts owed by a health plan to hospitals, non-contracted hospital-based physicians and others for emergency services. The definition specifically includes radiologists, pathologists, anesthesiologists and on-call specialists among the physicians to whom it applies.

In this balance billing issue and most others, the CMA is fighting to convince the DMHC to force HMOs to pay doctors fully for emergency services rendered outside of a contract. In this case, the association argues that while the new proposal imposes restrictions on how physicians can retrieve full payment for services, it does nothing to address the underlying problem of "chronic and pervasive underfunding of emergency care by HMOs," according to a statement.

While the DMHC notes in a notice of rulemaking that health plans are legally responsible under the Knox-Keene Act to pay for such emergency care, CMA doctors at previous balance-billing hearings clearly feel that its solutions for inadequate payments fall short. These include appealing to a plan's claims dispute resolution process, appealing to the DMHC's pilot dispute resolution process, or filing a civil lawsuit for full payment.