# Non par reimbursement - ANY NON-PAR TRAUMA BILLERS



## bill2doc (Dec 20, 2011)

Billing for non-par trauma doc's for professional services. Kaiser paid for a pt in full for my billied 99291 but not in full for my 99292 as they stated paid by customary and resonable fee and noted an adjustment.

Anyone billing for non-par. My understanding was they should be paid in full as they are not participating and under no contract. I don't know how to know what the reasonable/customary fee is.... Can I appeal ?  Can I balance bill the patient.

practicing in California

Thanks for your advice


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## ajs (Dec 20, 2011)

bill2doc said:


> Billing for non-par trauma doc's for professional services. Kaiser paid for a pt in full for my billied 99291 but not in full for my 99292 as they stated paid by customary and resonable fee and noted an adjustment.
> 
> Anyone billing for non-par. My understanding was they should be paid in full as they are not participating and under no contract. I don't know how to know what the reasonable/customary fee is.... Can I appeal ?  Can I balance bill the patient.
> 
> ...



Asked and answered in three other forum threads...


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## bill2doc (Dec 20, 2011)

Posted in three other forum threads but no quite answered.  I was hoping to reach non par docs operating in California....

What happens when an HMO plan member must obtain medical care in an emergency? The hospital he goes to for service and the doctors on duty there are obligated by law to provide the care needed to stabilize the patient. The HMO is also obligated by law to pay for its members' emergency care. A dilemma arises when the provider and the plan have not already agreed on how payment for services will be handled: how much must the plan pay, and is the provider obligated to accept the amount paid by the HMO as payment in full? Providers claim that plans are setting reimbursement rates unfairly, at sums too low to adequately pay for the services. Plans claim that providers are charging rates that are not fair, that are beyond the usual and customary charges for the location.

The California Supreme Court, in Prospect Medical Group vs. Northridge Emergency Medical Group (2009) 45 Cal.4th 497, ruled that California law requires that the dispute about payment for the out of network provider cannot involve the patient, but is between the provider who must render the care and the plan which is obligated to pay for the care. The provider cannot use balance billing to try to force the plan to pay more by putting economic demands on the patient, and plans cannot pay too little thereby forcing its members to pay the rest of a fair compensation to the provider. As a result, when a plan member in an emergency must get medical treatment from an out of network hospital or physician, his financial obligations are the exact same as they would be under the plan terms for in-network providers. The provider cannot bill the patient but must work out payment with the health plan.


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## ajs (Dec 20, 2011)

bill2doc said:


> Posted in three other forum threads but no quite answered.  I was hoping to reach non par docs operating in California....
> 
> What happens when an HMO plan member must obtain medical care in an emergency? The hospital he goes to for service and the doctors on duty there are obligated by law to provide the care needed to stabilize the patient. The HMO is also obligated by law to pay for its members' emergency care. A dilemma arises when the provider and the plan have not already agreed on how payment for services will be handled: how much must the plan pay, and is the provider obligated to accept the amount paid by the HMO as payment in full? Providers claim that plans are setting reimbursement rates unfairly, at sums too low to adequately pay for the services. Plans claim that providers are charging rates that are not fair, that are beyond the usual and customary charges for the location.
> 
> The California Supreme Court, in Prospect Medical Group vs. Northridge Emergency Medical Group (2009) 45 Cal.4th 497, ruled that California law requires that the dispute about payment for the out of network provider cannot involve the patient, but is between the provider who must render the care and the plan which is obligated to pay for the care. The provider cannot use balance billing to try to force the plan to pay more by putting economic demands on the patient, and plans cannot pay too little thereby forcing its members to pay the rest of a fair compensation to the provider. As a result, when a plan member in an emergency must get medical treatment from an out of network hospital or physician, his financial obligations are the exact same as they would be under the plan terms for in-network providers. The provider cannot bill the patient but must work out payment with the health plan.



Looks like an issue that you should take to the California State Medical Association Board.  
http://www.cmanet.org/

When it comes to contracting issues and legal battles that is who the docs here in Washington state turn to...our Washington State Medical Association board.  They are able to provide the most accurate guidance for legal issues.


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## SCCL5558 (Feb 11, 2013)

Bill2doc,

Did you ever get a definate answer on this?


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## bill2doc (Feb 12, 2013)

Sort of. I was told that for emergency services you cannot balance bill.  What I cannot get is the usual and customary fees the carriers come up with and we are forced to just "take what we get"


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## SCCL5558 (Feb 12, 2013)

So just so I have this right......you cannot balance bill for HMO emergency patients but you can balance bill PPO emergency patients? Are you having your providers contract with the HMO insurance companies?


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