Winter 2024 Issue
By: Anita Barooni and Karen George
“As we approach the one-year anniversary of AB 716, it is imperative for ground ambulance providers to understand how to enforce their reimbursement rights when noncontracted payors fail to comply with the bill’s requirements.
Pursuant to AB 716, the Health and Safety Code and the Insurance Code require health plans and health insurers to directly reimburse non-contracted ground ambulance providers at either (a) the rate established or approved by the jurisdiction in which the transport was initiated or if no such rate is established, then (b) the “reasonable and customary” value for the services rendered. The “reasonable and customary” value for the services rendered is based on statistically credible information that takes into consideration the following factors (i.e., the Gould factors):
(i) The provider’s training, qualifications, and length of time in practice;
(ii) The nature of the services provided;
(iii) The fees usually charged by the provider;
(iv) Prevailing provider rates charged in the general geographic area in which the services were rendered;
(v) Other aspects of the economics of the medical provider’s practice that are relevant; and
(vi) Any unusual circumstances in the case.”
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