June 25, 2001 Prompt Payment Workshop - Comments from attendees
Prompt payment compliance would improve if:
- The type of service codes needs to be defined. (Similar to place of service)
- The "audit" provision must be defined very clearly (Examples, exclusions, etc.).
- The rules should also clearly state that appealed claims that were not paid correctly the first time must be paid at billed charges.
- Mailbox rule in the new guidelines will need to be very detailed. What happens if a carrier says they never got it?
- Providers were educated on carrier´s responsibilities; TDI staff give answers to questions.
- Delegated entities receives member eligibility directory from source (i.e. state plan)
- Clarification of requirements prompt pay when an indemnity policy is within the contestable period. Many times medical records are needed in order to determine if the claim is payable. Providers notoriously delay providing these records, especially if the policyholder is to be reimbursed for the claim.
- Providers and manage care organizations understood each other´s processes clearly. Much of the non-payment is a result of low level staff members on both ends performing tasks without clear understanding of the "health care reimbursement process". Governing the process should start with education.
- If the department would actually "fine" the insurers/HMOs who have consistently demonstrated non-compliance patterns, the insurers/HMOs would finally believe that they are accountable and that the Department meant business.
- Need a Q&A period after each instructional presentation.
- Separate those entities that continuously do things to pay claims late or not pay. There are companies out there trying to do the right things. Mistakes will happen – why penalize for errors?
- Governor Perry had allowed HB1862 to pass.
- Enact rules regarding contracting with physicians and hospitals that prohibit provisions that circumvent the prompt-pay laws.
- Providers would provide requested information in a timely manner.
- Providers would review electronic submission, reject reports to determine claims not received, and review other payments to timely post payments.
- Providers would refrain from routinely resubmitting duplicate claims.
- Providers would verify from correct mailing address for insurer.
- It would be helpful if a special workshop was held for PPOs and other rented networks. I have numerous unanswered questions regarding PPO involvement in prompt pay (e.g. can a PPO be fined for its contracted carrier´s violation?).
- Claim is denied as deficient – required fields needed to process claim was not filled out.
- Provider is notified timely of the deficiency.
- Verify that a facility, provider resubmits a "corrected billing" – this would be viewed as a new claim submission. The provider did not include some additional charges on the original submission.
- Claims paid incorrectly within 45 days, providers should have specified timeframe to notify of incorrectly processing rather than wait until after 45 days to make the claim outside the statutory time frame to receive bill charges or contract penalty rate.
- We´re identifying members who were inpatient at facilities around Houston, identifying those who may have been moved, and entering out-of-area authorities in our system to facilitate payments of claims for HMO. Prompt payment must carry a zero tolerance policy. It is setting the goal that proves the seriousness – if set less than 100%, than it says the expectation is "we´re pretty serious but don´t expect you to do it right always."
- More information was shared with carriers by DOI. Many out of state companies do not receive proper information.
- Need more TDI rules shared specifically dealing with dental insurance.
- Lead time sufficient for new (8/01) rules for implementation will help greatly.
- All states would uniformly adopt rules – clean claim definitions – days to process, etc. Processing systems are universal – TDI imposed mandatory training against repeated offenders – both providers and HMOs, and insurers. HMOs and insurers must train all staff – utilizing material developed by them and approved by TDI.
- Contract delegated arrangements must be approved by TDI.
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Last updated: 11/20/2009