DMHC Proposes New Rules to Require HMOs to Disclose Physician Reimbursement Rates, Pay Claims Promptly

Officials from the Department of Managed Health Care have proposed new regulations that would "hold health insurers accountable" for paying physicians on time, the Los Angeles Times reports. While the state has a prompt-pay law, which requires insurers to pay providers within 45 days and allows the DMHC to sanction health plans for "unfair payment patterns," the proposed regulations would make it even more difficult for insurers to delay payments. For instance, the proposed rules, which have not yet been publicized, would prevent insurers from returning claims to providers along with a request for additional information, a practice that regulators contend health plans use to delay payments. The new rules also include more stringent HMO monitoring requirements and would mandate that insurers disclose their fee rates for procedures, services and bundled claims. Before any changes to the fee rates could be made, providers would have to be given 30-day notice. In addition, the new rules "would hold HMOs directly responsible for monitoring medical groups" with which they contract, requiring health plans to file quarterly reports on medical groups' compliance with the state's prompt-pay laws, the Times reports. According to the Times, the new rules are likely to be implemented this fall after a public comment period. Insurers, however, have objected to the rules, saying they are "one-sided, ... unnecessary, arbitrary" and would lead to higher costs for consumers (Lee, Los Angeles Times, 5/26).