Having large monopolies in the health care business certainly does not help issues..if everything meets current criteria without any additional information, it appears most of those filed electronically make the grade in 30 days or less; however, how many need additional information added?  This is what drags the procedure down to a crawl as one additional item of information starts a process of form letters, response letters, and even phone calls for follow up..so exactly what is a clean claim?  I don't think it is possible for all claims to be "clean", if you will, thus the continued delay in payment while going back and forth on some....others just flat out pay slow...but the industry states it is getting better...76 million in fines is a lot of money...what new certifications do physicians need to have or invest in to be guaranteed payment as being "certified" with each carrier...why do insurers find loopholes?  AMA pushing for Congress to address....BD

Like all physicians, orthopedic surgeon Frank B. Kelly, MD, depends on steady cash flow to keep his office running. But Dr. Kelly, who directs the seven-doctor Forsyth Street Ambulatory Surgery Center in Macon, Ga., finds himself constantly battling private insurance companies to get payment for patient claims. Even though Georgia law requires reimbursement within 15 days, Dr. Kelly says payment can take as long as six months. His financial situation gets so bad that he sometimes delays purchasing new equipment and sweats the months liability premiums come due. "You don't make plans for capital expenditures unless you have the money in hand," he says. "You cannot depend on being paid by an insurance company.

His office administrator, Melissa Zediker, relates the example of a claim for hand surgery. It included the surgeon's name and license number, but the insurer denied payment because the claim didn't state the doctor's degree.

By 2007, all 50 states had some form of law penalizing health insurers for late payments. Yet the problem persists, physicians say.  Insurers have found loopholes to get around the deadlines and are using federal law to slip out of state laws, doctors say.  States have imposed at least $76 million in fines in the past 10 years against insurance companies for failure to comply with prompt-pay laws, according to the AMA.

What is needed, says the American Medical Association, is a tough federal law penalizing insurance companies that delay payment.  One reason insurers can ignore prompt-payment laws is that they dominate the market in most communities, says Cecil B. Wilson, MD, immediate past chair of the AMA Board of Trustees. 

"Most of it is really ridiculous -- standard form letters in their system that they shoot off and hope the provider doesn't address," she explained. "A lot of these claims get paid down the road, but they hold the funds 30 to 90 days longer than if it went through with a 'clean' claim," she said.

AMNews: Nov. 5, 2007. The failed promise of prompt pay ... American Medical News


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