Pressure builds for prompt-pay measures
Pressure builds for prompt-pay measures
State groups push for new laws
Fed up with what they consider an arrogant attitude among insurers toward late payments and intentional downcoding, physicians are organizing to change the situation.
Medical societies in more than 40 states have begun documenting reimbursement delays by HMOs, which they plan to use to lobby local lawmakers to put the pressure on payers to pay up. One sample of some 6,000 claims filed last July by Ohio physicians, for instance, found 42% of undisputed claims had not been paid within the state’s statutory 24-day deadline. Meanwhile, 20% of claims remained unpaid 60 days after being filed.
Getting results
Florida providers scored a victory in March when Humana agreed to put a stop to its policy of automatically challenging bills for complicated patient office visits. The insurer also agreed to institute an expedited downcoding appeals process.
Humana says it will launch an automatic nationwide review of 5,000 of its physicians, including 1,500 in Florida, who file significantly more complicated medical claims than their peers.
Nationally, a coalition of medical specialties is pressing Congress to expand current Medicare prompt payment requirement to all plans. "Inclusion of a prompt payment provision is critical to providers, who must struggle daily to obtain payments legally owed them," coalition leaders testified on Capitol Hill.
"We understand some payers use a general payer denial code of $1.25 above contractual agreed-upon price by erroneously mispricing relative value units," explains Robert Doughtery, head of public affairs for the American College of Physicians-American Society of Internal Medicine.
Other payers "lose" claims — forcing practices to send them by certified mail or courier service — or habitually transfer claims from one department to another, he notes. That forces some providers to add administrative staff just to deal with the increased work caused by these slight-of-hand delay tactics.
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