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California Out of Network/Surprise Billing Laws and Process

California-billing (1)

Introduction

When a medical service provider attends to a patient without getting a contract with his insurance plan, his services are called out-of-network. The charges for these services are called OON billing and the situation can occur due to several reasons. For example, when a patient visits the hospital in an emergency, service providers attend to him without his network confirmation. OON services can cause surprise billing and higher-cost treatments.

The charges on the patient for OON services are called surprise billing. The term surprise is used because the patient receives an unexpected bill for using OON providers. Surprise billing occurs when a patient receives emergency care from an in-network facility but is treated by OON providers. These bills charge high rates because insurance rates do not bind OON services. California introduced several laws to save patients from this financial stress.

California’s Out-of-Network (OON) Law (AB 72)

  • This OON law ensures that patients only share the cost of in-network services. OON providers cannot serve the patient without his consent, and in emergent situations, the in-network facilities use their services to share the cost. This law took effect on July 1, 2017, and it shares the balance billing burden on patients.
  • This legislation compensates non-participating providers through commercial payors such as DHCS and CDI. According to state law, the compensation rate is the average of contracted insurance for the same service and region. The rate is also decided as 125% of in-network Medicare prices.
  • This plan benefits patients and service providers. Patients avoid surprise and balance billing hassles, and service providers receive a fair amount of compensation. When a transparent decision is made on balance billing, the law enhances patients’ trust in the state’s healthcare arrangements.

The Federal No Surprises Act (NSA)

This federal act saves patients from surprise billing for non-emergency and emergency conditions. This law takes effect on January 1, 2022, and is equally beneficial in all US states, including California. The implementation of this legislative step applies to several health insurance plans, including ERISA.

Applicability to California

The application of federal NSA in California provides additional protection to existing state laws. This act added self-funded and ERISA insurance plans that were previously out of scope in the state’s legislation.

Coverage for Emergent and Non-Emergent Care

According to NSA, OON providers cannot charge for their emergency services, and patients will share the cost of in-network services. The patient is free from balance billing in emergency treatment, regardless of whether the services are in-network or OON.

Self-Funded/ERISA Insurance Plans

The act provided the same protection to self-funded insurance and state-regulated plans, which provides extra protection for healthcare facilities. Self-funded and ERISA insurance plans are handled at the federal level, so patients receive extra protection by adding these plans to the federal NSA.

Consumer Protections Under California Law

The state introduced several guidelines for protecting consumers from unexpected payments for medical services. The primary focus of these practices is preventing surprise billing.

Balance Billing Prohibitions

According to this act the service providers cannot impose charges of difference between insurance coverage and OON expenses. The payment disputes should be settled between insurers and service providers. By these instructions, the patient receives quality care without financial burden.

Emergency Services Coverage

The medical emergency does not allow enough time to choose the network status according to the patient’s insurance. Hence, to provide timely medical assistance for patients, the state allows insurers to cover emergencies without the concern of in-network service or the OON.

Patient Rights and Responsibilities

Patients must understand their rights and responsibilities because a deep knowledge guides them to navigate the medical complexities efficiently. According to California rules, patients have the right to make consent decisions about network selection and can access their medical records.

With certain rights, it’s their responsibility to understand the insurance structure. They should follow the instructions of professionals during treatment. They should timely apply for the IDR process in case of surprise billing and ensure submission of all relevant documents to resolve payment disputes.

The Independent Dispute Resolution (IDR) Process

Mediation vs. Arbitration

Both processes are types of IDR and are used to resolve the differences between insurers and service providers. These types save the cost and time of litigation steps and allow both parties to resolve the issues confidentially. In mediation, the third party creates a positive environment for both parties to negotiate and solve the issue with common interests. Conversely, the arbitration process allows the third party to impose a final decision after collecting evidence and information from both parties.

Role in Resolving Billing Disputes

Arbitration and Mediation help compensate service providers for their OON services. Both processes work like a defensive shield for patients by preventing their involvement in billing disputes. The IDR process also resolves issues without legal involvement.

Recent Developments and Statistics

California is continuously enhancing the IDR process to resolve payment issues fairly and efficiently. A recent development of expanding the IDR to attend OON services in emergencies increased patient protection. The state is going to set criteria for selecting mediator parties. The selection based on higher qualifications and experience will increase the transparency of decisions.

Health Care Providers’ Considerations

The state introduced specific conditions to prevent service providers’ payment loss. These guidelines help compensate for non-covered services and ensure a smooth treatment process for patients.

Billing for Non-Covered Services

In emergency treatment, service providers cannot receive the charges for OON services. However, for non-emergency treatment, providers are responsible for informing the patients regarding their network status in advance. They should also get patients’ consent signatures on hospital documents to prevent any disputed situation.

Working at In-Network Facilities as Out-of-Network Providers

OON providers working at in-network facilities can create a confusing situation for patients. They should clearly inform patients about their network status and directly negotiate with insurers for cost coverage. Such providers can also initiate the IDR process to resolve their payment disputes.

Requesting Arbitration

Providers should have comprehensive knowledge of the state’s laws and requirements to start the arbitration. They should also have all relevant documents before applying for arbitration. Preparation guides to timely follow-ups for requests.

Health Plan Provider Directory Requirements

Californian health directories must comply with state requirements. This alignment helps to spread up-to-date information to patients so that they can make informed decisions.

Listing by Specialty

The service providers on directories should be available on their specialty basis. The developers can classify these specialties into subcategories to provide more accuracy in search results.

Availability & Updates

These directories should be mobile-friendly and available f4/7 without any login requirements. For patients, The developers should create multiple formats of one directory, such as online, print form, or downloadable in PDF format. The planners should regularly update the directory to provide accurate information about availability.

Final Analysis

California developed favorable rules and regulations for patient protection. The state’s laws benefit both service providers and patients. If the acts save patients from surprise billings, the providers also receive compensation from state payers. Authorities are continuously striving to enhance California’s healthcare landscape.

Out of Network billing service providers like Wise Medical Billing keep itself up to date with ever evolving landscape of healthcare regulations and is continuously helping Out of network providers getting a fair reimbursement for the valued services they provide to their patients.

Reach out to us to know more about Wise Medical Billing Out of network complete revenue cycle management services Today.

Call us at 302-496-3002 or email us at info@wisemedicalbilling.com

    Injection & Pain Management

    We provide compliant billing for foot injections, nerve blocks, and pain management procedures with accurate documentation and proper modifier usage.

    Advanced Treatments

    We handle advanced podiatric treatments with proper prior authorization management and comprehensive clinical documentation for high-value services.

    Nail & Skin Procedures

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    Surgical Procedures

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    Diabetic Care Management

    We coordinate diabetic foot care services with proper medical necessity documentation and systematic condition correlation for comprehensive treatment.

    Orthotic Services

    We provide specialized billing for custom orthotics and devices, ensuring proper HCPCS and ICD-10 code pairing to justify fitting and delivery documentation.

    Routine Care & Diagnostics

    We handle routine foot care according to strict medical necessity criteria, ensuring precise paperwork and accurate coding for debridement and mycotic nail care, with proper frequency documentation.

    Wound Care Partnerships

    We provide accurate code coordination to prevent overlapping, ensure transparent tracking for pre- and post-surgical services, and deliver complete operative notes with reduced errors.

    Graft & Skin Substitute Procedures

    We select accurate application and graft codes based on location and wound size, audit surgical documents to ensure correct Q-code pairing for procedures and supplies, and assist in navigating state-specific Medicaid nuances through proactive prior authorization.

    DME Billing

    Robust compliance for orthotics, diabetic shoes, walking boots, and offloading devices. We ensure that certified coders are used for accurate coding and a perfect match for every claim. We evaluate the signature requirements of every payer and employ proactive strategies for expedited prior authorization.

    Injection Therapies

    We handle foot injection procedures with accurate MCO compliance, ensuring proper documentation and modifier usage for maximum reimbursement in the NY market.

    Nail & Skin Care

    We provide compliant billing for nail debridement and skin lesion procedures, meeting eMedNY-specific documentation requirements and ensuring proper medical necessity justification.

    Advanced Treatments

    We manage advanced podiatric treatments with NY-specific requirements, ensuring proper Q-code usage, comprehensive clinical packets, and expedited prior authorization processes.

    Diabetic Care Management

    We coordinate diabetic foot care services with wound care partnerships, ensuring proper documentation and transparent billing coordination for all involved providers.

    Surgical Procedures

    We handle complex podiatric surgeries with MCO coordination, ensuring accurate service sequencing and proper documentation to prevent overlapping claims and denials.

    Orthotic Services

    We provide specialized eMedNY-compliant orthotic billing with precise HCPCS coding, accurate ICD-10 pairing, and comprehensive modifier knowledge for maximum reimbursement.

    Routine Care & Diagnostics

    We ensure eMedNY compliance for routine foot care services with systematic condition documentation, proper modifier alignment, and comprehensive medical necessity justification for all procedures.

    Graft & Skin Substitute Procedures

    We prepare comprehensive clinical packages for fast approval, ensure thorough compensation for graft products and application, and prevent claims denials through accurate coding and correct submission.

    Wound Care Partnerships

    We provide accurate code coordination to prevent overlapping, ensure transparent tracking for pre- and post-surgical services, and deliver complete operative notes with reduced errors.

    DME Billing

    NY Medicaid’s top coverages include diabetic shoes and inserts, ankle-foot orthoses, braces, and custom-molded orthotics. We ensure eMedNY compliance through precise documentation, proper ICD-10 coding, and in-depth knowledge of modifiers to prevent denials.

    Robotic Procedures

    We deal with complex billing for radical prostatectomy, partial nephrectomy, and cystectomy by elaborative documents for the used devices. Our accurate codes and modifiers ensure successful approvals.

    Telehealth

    Our coders ensure accuracy for pre-op consultations, follow-ups, and LUTS/OAB management. Our optimized POS and use of modifiers have lower denial rates, as we demonstrate their necessity with clinical documents.

    Urodynamics & Diagnostics:

    We handle multi-channel involvement and billing complications with detailed CPT/ICD pairing. Our proactive prior authorization handling and expert claim structuring ensure error-free approvals.

    Cystoscopy & Endoscopy:

    We capture every detail and require evidence to ensure a smooth claim approval for office-based and hospital-based endoscopic procedures. We offer robust billing claims for biopsies and stone removals.

    Lithotripsy (ESWL) & Stone Management:

    We understand the complex bundling of ESWL, URS, and stone procedures, including device charges, anesthesia, and supplies for ongoing care. This in-depth knowledge ensures coding accuracy for each component.

    Prostate Procedures & Biopsy:

    We offer meticulous billing for targeted biopsies and imaging-guided prostate procedures, ensuring proper coordination of involved pathology and detailed capture of all allowable charges.

    Implants & Prosthetics

    We strictly follow the payer’s rules for high-value penile prostheses and testicular implants, ensuring proper coverage for device charges. Our coders ensure proper coding pairs, transparent vendor contracts, and logs for implants.

    Pathology & Imaging

    Our team possesses in-depth knowledge of the working principles of pathology and imaging centers. We collaborate with service providers to obtain accurate clinical information, ensuring that we capture all allowable charges.

    Botox & Neuromodulation

    For these complex services, we provide thorough coverage by handling prior authorization approvals and ensuring coding accuracy for both trial and permanent procedures. Our modifier’s accuracy provides high compliance with diverse payer requirements.

    DME & Catheter Supplies:

    We provide streamlined billing claims for catheter and drainage bag supplies, ensuring smooth and timely payment collections. Our proof-of-delivery and proactive SOPs save practices from financial loss.

    DME & Catheters

    We handle catheter supplies, ongoing maintenance claims, and billing for incontinence aids. We complete clinical documents with proof of need, supply evidence, and other supporting elements according to Medicaid requirements.

    Pathology & Advanced Imaging

    Outpatient labs and imaging services face facility-based billing cuts due to poor classification. We manage all complexities with professional splits and ensure compliant claims for radiology reads and pathology services.

    Botox & Neuromodulation

    We perfectly align the trial with a permanent implant and explain all stages with accurate codes. Our precise and error-free claim submission ensures maximum reimbursement for all elements.

    Implants & Prosthetics

    We offer support for commercial or Medicaid billing claims through transparent device tracking, fair vendor contracts, and compliant pre-auths, resulting in the successful implantation of penile prostheses, urinary sphincters, or slings.

    Prostate Procedures & Biopsies

    Pairing of biopsies with MRI-guided prostate means additional care for billing documents. These coordinated services required accurate pathology linking, ensuring that our robust component captures the necessary information.

    Lithotripsy & Stone Procedures

    We offer coding accuracy from ESWL to ureteroscopy by managing compliant documents for anesthesia, professional components, and prior authorization for such high-value services.

    Cystoscopy & Endoscopic Interventions

    Our technical expertise ensures billing accuracy for stent removals, cystoscopy, and facility-based endoscopy procedures. We separate each component of treatment to bring payment for all.

    Urodynamics & Pelvic Testing

    We justify the clinical necessity for urodynamic services. We offer hands-on support for authorization, ensure claims accuracy with diagnosis justifications, and document compliance for revisits.

    Telehealth Evaluation Services

    We have current information about eMedNY and MCO policies, ensuring coding accuracy with proper place-of-service designations, relevant modifiers, patient consent forms, and explanations of rendered services.

    Robotic Procedures

    We cover high-value procedures such as prostatectomy and nephrectomy, among others, by accurately documenting device costs in clinical documents and justifying their necessity under APG and facility-based insurance rules.

    Pathology & Imaging Coordination

    We resolve coding conflicts for these pairing services and ensure a justified coordination in documents to prepare a clean claim with reduced denial risks.

    DME & Catheter Supply Managemen

    The Medi-Cal and commercial payers have strict compliance requirements for DME. We streamline your claims with transparent usage tracking to ensure quality care and justified reimbursement.

    Botox, Neuromodulation & OAB Treatments

    We simplify the staged billing process for trials by managing prior authorization, the device’s paperwork, and submitting claims to accurate insurers to make it more manageable.

    Implants & Prosthetics

    We expedite your operation by handling authorization and vendor contracts, managing paperwork for pre-approvals, ensuring coordination, and maintaining inventory logs for stents and penile implants.

    Prostate Procedures & Biopsies

    Our experts accurately sequence the complex billing claims for MRI-fusion biopsies, prostate services, and imaging pairings across various payers to ensure maximum reimbursement for practices.

    Lithotripsy & Stone Procedures

    We navigate the complex process through accurate coding, transparent anesthesia reports, and the use of durable equipment, resulting in maximum coverage for every service.

    Cystoscopy & Endoscopic Interventions

    We capture each detail about scope procedures, stent placements, and biopsies performed in facility or ASC settings to prepare compliant claim documents.

    Urodynamics & Pelvic Testing

    We understand the unique compliance requirements, from bladder studies to pelvic floor testing, which prove the clinical necessity to ensure robust prior authorization and successful billing claims.

    Telehealth Evaluation Services

    California has broader telehealth services, with high Medi-Cal reimbursement for these services. We cover modality, consent, and explain facility settings so that you can get maximum advantage from every allowed charge.

    Robotic Procedures

    We precisely document robotic-assisted surgeries, negotiate with insurers, reflect the procedure’s complexity, and complete all paperwork in accordance with payer requirements to ensure a justified payment.

    AB 72 – Surprise Billing Law

    For podiatrists providing surgical services in out-of-network facilities, California’s AB 72 limits balance billing. Navigating this requires precise billing strategies.

    Prior Authorization Hurdles


    Increasingly, California payers require prior authorizations for DME, orthotics, skin grafts, and advanced wound care procedures. Failure leads to non-payment.

    Workers’ Compensation Complications

    California’s Workers’ Compensation system demands strict adherence to the Official Medical Fee Schedule (OMFS) and highly detailed documentation—especially for podiatric injury care, fracture management, and surgical interventions

    Complex Wound Care & Skin Graft Billing

    Podiatrists collaborating with wound care centers for diabetic ulcers, pressure sores, or limb salvage procedures face frequent denials related to skin substitute grafts (e.g., Apligraf®, Dermagraft®) and advanced wound treatments like NPWT (vacuum therapy).

    Medi-Cal Restrictions

    Medi-Cal limits podiatry services unless directly related to chronic disease management. Denials are common without proper coding and documentation.

    Routine Foot Care Scrutiny

    California insurers, including Medi-Cal and major HMOs (Kaiser, Blue Shield CA), often classify foot care (like nail debridement and callus removal) as non-covered unless medically justified by conditions like diabetes or peripheral vascular disease.