Archive for September, 2011

Quotes

September 29, 2011

“Excellence is not an accomplishment. It is a spirit, a never-ending process.”  – Lawrence M. Miller

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How does the Prompt Pay Law affect Non-Contracted Providers?

September 26, 2011

The Texas Department of Insurance oversees and handles all complaints from physicians and providers about carriers who are failing to comply with the prompt payment requirements of Articles 3.70-3C, §3A and 20A.18B of the Texas Insurance Code and Department rules.  The Department is committed to achieving full company compliance with the prompt payment statutes and rules.

This article is to remind you of your responsibility to comply with the prompt payment laws for non-contracted physicians and providers and review some basic requirements that carriers must follow for making prompt payments to non-contracted physicians and providers.

For complete information on all of the required claims processing procedures to comply with Texas statutes and Department rules, refer to the appropriate provisions of the Texas Insurance Code and the Texas Administrative Code. Also, review the Prompt Payment Statutes and rules to verify that your internal procedures comply with these requirements.

NON-CONTRACTED PROVIDERS

Fee-for-service (indemnity plans) and preferred provider plans. When there is no contractual relationship between the physician or provider and the insurer, the insured may make an assignment of benefits to the physician or provider. This includes instances in which an insured in a fee-for-service or indemnity plan makes an assignment of benefits to a physician or provider or if an insured in a preferred provider plan receives services from a non-network provider and makes an assignment of benefits. Under Article 3.51-6, §1(d)(2)(x) (group health plans) and Article 3.70-3, §(A)(8) (11) (individual policies) of the Texas Insurance Code, the insurer must pay all benefits payable under the policy within 60 days after receipt of proof of loss.

HMOs. If an HMO enrollee receives services from a non-network physician or provider through a referral (as outlined in Article 20A.09(a)(3)(C)) of the Texas Insurance Code or emergency services from a non-network physician or provider (no referral needed), the HMO must make payment to the non-network physician or provider within 45 days after receiving the claim. The claim must include documentation reasonably necessary to process the claim and must be for covered services, as provided in Article 20A.09(j).

In situations where the enrollee or insured does not make an assignment of benefits or an authorization of payment to the physician or provider, the HMO or insurer will directly reimburse the enrollee or insured. The physician or provider can then obtain payment from the enrollee or insured.

ENFORCEMENT

The Department investigates all complaints alleging non-compliance with the requirements of the prompt payment statutes and rules. If allegations are substantiated, the Department may impose any authorized sanctions and penalties, including suspension or revocation of the carrier´s license to conduct the business of insurance in Texas. Other regulatory compliance options include administrative oversight, commissioner´s orders with fines, corrective action plans, management conferences, and reporting/monitoring requirements. In addition, if allegations of violation of Articles 3.70-3C, §3A and 20A.18B and 28 TAC §§21.2801-21.2815 are substantiated, the Department may impose administrative penalties of up to $1,000 per day for each claim that remains unpaid in violation of the prompt payment requirements.

Quotes

September 22, 2011

“Determination: Your end result will be in direct proportion to the intensity of your desire.”  – Napoleon Hill

How does the Prompt Pay Law affect Contracted Providers?

September 19, 2011

The Texas Department of Insurance oversees and handles all complaints from physicians and providers about carriers who are failing to comply with the prompt payment requirements of Articles 3.70-3C, §3A and 20A.18B of the Texas Insurance Code and Department rules.  The Department is committed to achieving full company compliance with the prompt payment statutes and rules.

This article is to remind you of your responsibility to comply with the prompt payment laws for contracted physicians and providers and highlights some basic requirements that carriers must follow for making prompt payments to contracted physicians and providers.

For complete information on all of the required claims processing procedures to comply with Texas statutes and Department rules, refer to the appropriate provisions of the Texas Insurance Code and the Texas Administrative Code. Also, review the prompt payment statutes and rules to verify that your internal procedures comply with these requirements.

CONTRACTED PROVIDERS

Applicable Statutes and Rules. Article 3.70-3C, §3A specifies claims processing procedures and prompt payment requirements for preferred provider carriers when processing claims filed by contracted physicians and providers. Article 20A.18B specifies these same types of requirements for HMOs.

The rules implementing these statutes are found at Title 28 of the Texas Administrative Code (TAC), §§21.2801-21.2815. The rules apply to all claims filed for non-confinement services, treatments, or supplies rendered on or after August 1, 2000, and to claims filed for services, treatments, or supplies for in-patient confinements in a hospital or other institution that began on or after August 1, 2000.

Statutory Timelines. If a physician or provider submits a “clean claim” as defined in §§21.2802 and 21.2803, the carrier has 45 days after receipt of the claim to do one of the following:

  • pay the total amount of the claim in accordance with the contract;
  • deny the entire claim after a determination that the carrier is not liable and notify the physician or provider in writing why the carrier will not pay the claim;
  • pay the undisputed portion of a claim and deny the remainder after a determination that the carrier is not liable for the remainder of the claim and notify the physician or provider in writing why the carrier will not pay the denied portion of the claim;
  • pay the undisputed portion of the claim, notify the physician or provider in writing that the remainder of the claim will be audited and pay the physician or provider 85 percent of the contracted rate on the unpaid portion of the claim; or
  • notify the physician or provider in writing that the entire claim will be audited and pay the physician or provider 85 percent of the contracted rate on the claim.

When a carrier acknowledges coverage but decides to audit a claim, it must pay 85 percent of the contracted rate on the claim within 45 days. After the audit is completed, the carrier must make any additional payment within 30 days. Physicians and providers who owe refunds to a carrier must make them within 30 days after the physician or provider receives the audit results, or after the exhaustion of any covered person´s appeal rights if the appeal is filed within the 30-day refund period, whichever comes later. A carrier that fails to comply with the claims payment requirements is liable for payment of the full amount of billed charges submitted on the claim or the contracted penalty rate set forth in the contract between the physician or provider and the carrier. In addition, the Department may impose regulatory remedies and sanctions for non-compliance (as explained in the Enforcement section of this bulletin).

For prescription benefit claims, the carrier must pay electronically submitted prescription claims that are electronically adjudicated and electronically paid within 21 days after authorizing treatment.

If you pend taking action on a clean claim without complying with these requirements, you are not in compliance with the clean claims rules.

Claims Address. The carrier is required by rule to disclose to the physician or provider the following information:

  • an address where claims are to be sent for processing;
  • a telephone number for questions regarding claims;
  • the name, address, and telephone number of any entity to which claims payment functions have been delegated; and
  • the address and telephone number of any separate claims processing centers.

A carrier may not, after a change of claims payment address or a change in delegation of claims payment functions, deny a clean claim on the basis that a physician or provider failed to file the claim within any contracted time period, unless the carrier provided at least 60 calendar days prior written notice of the address or delegation change. A carrier may not fail to acknowledge receipt of a claim sent by certified or registered mail.

If you change the address to which the physician or provider must send the claim and do not give the required written notice and subsequently fail to act upon a clean claim within the statutory payment period or refuse to accept a clean claim because it was sent to the incorrect address, you are not in compliance with the clean claims rules.

Alteration by Contract. Statutory requirements, such as the prompt payment periods, may not be changed by contract (except that the 45-day payment period may be shortened by contract). Carriers may alter by contract some of the prompt payment requirements such as data elements and attachment requirements.

If you use contract provisions to lengthen the statutory prompt payment periods, you are not in compliance with the clean claims rules.

Attachments and Additional Elements. Carriers may revise their requirements for additional attachments and clean claims elements upon proper notification. The physician or provider must be notified at least 60 calendar days before the carrier may require the additional attachment or element.

If you are requiring physicians or providers to submit attachments for which you have not given proper notification in accordance with the rules, you are not in compliance with the clean claims rules.

Quotes

September 15, 2011
“The only difference between successful people and unsuccessful people is extraordinary determination.”  – Mary Kay Ash, Entrepreneur

Prompt Pay Law definition

September 12, 2011

Prompt Payment to Providers

28 TAC §§21.2801-21.2816

When Does a Company Have to Pay a Claim for a Health Service?

  • Texas law provides different requirements depending upon:
    • Type of coverage – HMO vs. PPO vs. Non-network Indemnity
    • Who filed the claim – Insured, Enrollee, Physician, or Provider
    • Status of physician or provider – Contracted vs. Non-contracted

Clean Claim Rules

Meant to implement and clarify HB 610 passed during 1999 legislative session

  • Apply to:
    • HMOs
    • PPOs
    • Contracted Physicians and Providers
  • Effective for:
    • Claims filed for outpatient care received on or after 8/1/00
    • Claims filed for inpatient stays that began on or after 8/1/00
  • Clean Claim Rules
  • Perform three main functions:
    • Define elements of a clean claim
    • Clarify when the prompt payment period clock starts running
    • Clarify the required actions of a carrier upon receipt of a clean claim

What is a Clean Claim?

  • Data elements – see handouts
    • HCFA 1500
    • UB-92
  • Attachments
  • Additional clean claim elements
  • Format
    • Legible, accurate, complete
    • Too much information does not render an otherwise clean claim deficient!

Proof of Claims Submission

  • Return receipt
  • Electronic confirmation
  • Fax confirmation

What are the Carrier´s Responsibilities?

  • Notice of revised or additional data elements and/or attachments. Disclosure may be made by:
    • Written notice at least 60 days prior to requiring additional or revised information
    • Revision of physician or provider manual at least 60 days prior to requiring additional or revised information
    • Contract provisions
  • Act on clean claims within 45-day statutory claims processing period
    • Pay the claim, in total, in accordance with the contract
    • Deny the claim in total and notify the physician or provider in writing of the reason for denial
    • Pay portion and deny portion, and notify physician or provider in writing of reason for denial
    • Pay portion and audit portion, notify physician or provider in writing that claim is being audited, and pay 85% of the contracted rate on the audited portion
    • Audit entire claim, notify physician or provider in writing that claim is being audited, and pay 85% of the contracted rate
  • Notice of deficient claims within 45 days
  • Notice of changes in claims addresses, processors, etc.

Audits

  • Carrier acknowledges coverage of an enrollee, but claim processing takes longer than the 45-day statutory claim processing period
  • The rule does not specify a time limit for audit completion
  • After the audit is completed the carrier must give written notice of the results and pay the additional 15% balance of contracted rate 30 days after the audit is completed
  • A physician or provider must refund the 85% audit payment:
    • 30 days after the later of (a) receiving notice of audit results, or (b) exhaustion of enrollee’s appeal rights, if appealed within 30-day refund period
    • Chargebacks are allowed with written notice and opportunity to arrange an alternative reimbursement method

Penalties if Carriers Fail to Comply with the Clean Claim Rules

  • Full amount of billed charges up to U&C charges, or
  • Contracted penalty rate provided for in the physician or provider’s contract
  • Administrative penalties, up to $1,000/day per claim, may be assessed and collected by the State of Texas

Date of Claim Payment

  • Claim is considered to have been paid on the date of:
    • U.S. Postal Service postmark
    • Electronic transmission
    • Delivery of the claim payment to a commercial carrier, such as UPS or Federal Express, or
    • Receipt by the physician or provider, if a claim payment is made other than provided above

Coordination of Benefits

  • The amount(s) paid by primary carrier(s) is a clean claim element for secondary carriers
  • The statutory claim processing period for secondary carriers does not begin until primary payor information is provided

Did you ever wonder how Meet Up started?

September 11, 2011

If you are like me…you don’t always know the story behind how something began…how the idea formed, what was the motivation, how it all happened.  Everyone has a story…Read the story of how Meet Up was formed!

***********************************************

Fellow Meetuppers,

I don’t write to our whole community often, but this week is special because it’s the 10th anniversary of 9/11 and many
people don’t know that Meetup is a 9/11 baby. Let me tell you the Meetup story.

I was living a couple miles from the Twin Towers, and I was the kind of person who thought local community doesn’t matter much if we’ve got the internet and tv. The only time I thought about my neighbors was when I hoped they wouldn’t bother me. When the towers fell, I found myself talking to more neighbors in the days after 9/11 than ever before. People said hello to neighbors (next-door and across the city) who they’d normally ignore. People were looking after each other, helping each other, and meeting up with each other. You know, being neighborly.

A lot of people were thinking that maybe 9/11 could bring people together in a lasting way. So the idea for Meetup was
born: Could we use the internet to get off the internet – and grow local communities?  We didn’t know if it would work. Most people thought it was a crazy idea — especially because terrorism is designed to make people distrust one another. A small team came together, and we launched Meetup 9 months after 9/11.

Today, almost 10 years and 10 million Meetuppers later, it’s working. Every day, thousands of Meetups happen. Moms Meetups, Small Business Meetups, Fitness Meetups… a wild variety of 100,000 Meetup Groups with not much in common – except one thing.  Every Meetup starts with people simply saying hello to neighbors. And what often happens next is still amazing to me. They grow businesses and bands together, they teach and motivate each other, they babysit each other’s kids and find other ways to work together. They have fun and find solace together. They make friends and form powerful community. It’s powerful stuff. It’s a wonderful revolution in local community, and it’s thanks to everyone who shows up.

Meetups aren’t about 9/11, but they may not be happening if it weren’t for 9/11.  9/11 didn’t make us too scared to go outside or talk to strangers. 9/11 didn’t rip us apart. No, we’re building new community together!!!!

The towers fell, but we rise up. And we’re just getting started with these Meetups.

Scott Heiferman (on behalf of 80 people at Meetup HQ)
Co-Founder & CEO, Meetup
September 2011
Meetup, PO Box 4668 #37895, New York, New York 10163-4668

Quotes

September 8, 2011
“Men are anxious to improve their circumstances, but are unwilling to improve themselves; they therefore remain bound.”  -James Allen

Essential Data Elements for a HCFA1500

September 6, 2011

 

Data Elements that are required:

Field # Data Element
1a Subscriber´s or patient´s plan ID number
2 Patient´s name
3 Patient´s date of birth and gender
4 Subscriber´s name
5 Patient´s address (street or post office box, city, zip)
6 Patient´s relationship to subscriber
7 Subscriber´s address
10 Whether patient´s condition is related to employment, auto accident, or other accident
11 Subscriber´s policy number
11a Subscriber´s birth date and gender
11c HMO or preferred provider carrier name
11d Disclosure of any other health benefit plans*
12 Patient´s or authorized person´s signature or notation that the signature is on file with the physician or provider
13 Subscriber´s or authorized person´s signature or notation that the signature is on file with the physician or provider
14 Date of current illness, injury or pregnancy
15 First date of previous, same or similar illness
21 Diagnosis codes or nature of illness or injury
24A Date(s) of service
24B Place of service codes
24C Type of service code
24D Procedure/modifier code
24E Diagnosis code by specific service
24F Charge for each listed service
24G Number of days or units
25 Physician´s or provider´s federal tax ID number
28 Total Charge
31 Signature of physician or provider or notation that the signature is on file with the HMO or preferred provider carrier
32 Name and address of facility where services were rendered (if other than home or office)
33 Physician´s or provider´s billing name and address

(unless otherwise agreed to by contract)

* If answer in field 11d is “Yes”, then data elements in fields 9, 9a, 9b, 9c, and 9d must be completed. If answer is “No”, then fields 9, 9a, 9b, 9c, and 9d are not essential data elements if the physician or provider has on file a statement signed by the patient/insured within the last 12 months that there is no other coverage. Such statement may be in the form of initial or annual office visit questionnaires, patient sign-in sheets, a routine record update, etc.

 

Data Elements that are necessary, if applicable:

Field # Data Element
9 Other insured´s or enrollee´s name – applicable if Field 11d is answered “yes”*
9a Other insured´s or enrollee´s policy/group number – applicable if Field 11d is answered “yes”*
9b Other insured´s or enrollee´s date of birth – applicable if Field 11d is answered “yes”*
9c Other insured´s or enrollee´s plan name (employer, school, etc) – applicable if Field 11d is answered “yes”*
9d Other insured´s or enrollee´s HMO or insurer name – applicable if Field 11d is answered “yes”*
11b Subscriber´s plan name (employer, school, etc.) – applicable if health plan is a group plan
23 Prior authorization number – applicable when prior authorization is required
27 Whether assignment was accepted – applicable when assignment under Medicare has been accepted
29 Amount paid – applicable if an amount has been paid by or on behalf of the patient or subscriber or by a primary plan
30 Balance due – applicable if an amount has been paid by or on behalf of the patient or subscriber

(unless otherwise agreed to by contract)

* If answer in field 11d is “Yes”, then the data elements in fields 9, 9a, 9b, 9c, and 9d must be completed unless the physician or provider submits proof of a good faith but unsuccessful effort to obtain this information from the enrollee/insured.

Quotes

September 1, 2011

“Pleasure in the job puts perfection in the work.”   – Aristotle

Texas Workforce Commission Spring/Summer 2011 Publication

September 1, 2011

Have you read the Texas Workforce Commission Winter 2011 publication?  It is now available online.  Click the link here to read or save your copy: http://www.twc.state.tx.us/news/tbt/tbt0711.pdf