Texas Medical Society hits late payers head-on
Group gets 75% success rate in collections
How many times have your staff griped about late payments from insurers, but failed to take any action? In response to member complaints, the Austin-based Texas Medical Association turned to action, with strong results.
"Many Texas physicians have been forced to take out bank loans to combat the rapid spread of what we call the 'low pay, slow pay, no pay' syndrome," says Bohn D. Allen, MD, chair of the Texas Medical Association's Socioeconomic Committee.
Texas lawmakers jumped on the slow-pay bandwagon last year with new laws requiring HMOs and other insurers to pay providers for covered services within 45 days of receiving properly completed claims. The legislation also requires health plans to make capitation payments within 60 days of a member selecting or being assigned to a primary care physician.
Despite this action, "physicians still found their claims were not getting paid on time," says Bradley Reiner, manager of payer relations at the Texas Medical Association (TMA) in Austin.
In response, the association instituted its Payment Equity Initiative, a get-tough education effort designed to give physicians the leverage and techniques they need to deal with payers who do not pay on time.
Keeping track of compensation problems
One tool they use is the so-called hassle factor log. The log is a simple record the physician's office keeps of any and all problems with health insurance, workers' compensation, or managed care payments. It permits providers to document any recent hassles they have had with payers.
"With this information at our fingertips, we can go through the log and determine what advice is most appropriate, then prepare a letter to be sent to the plan's medical director precisely outlining the problem and things which we feel need to be corrected," says Reiner.
One unusual tactic the TMA recommends to its physicians is to recruit willing patients to help get the claim paid. The physician, for instance, will have an already-prepared letter for the patient to send to the HMO, saying the patient wants the plan's dispute with the physician to be quickly resolved. "We feel the insurer will listen closer if the person who's insured takes the time to get involved and sign a letter," says Reiner.
If that does not produce payment, the association's next step is to send a follow-up letter containing the log's contents to the Texas Department of Insurance. "We're especially inclined to notify the insurance commissioner when we uncover a pattern of abuse or quality issues we think merit immediate attention," Reiner notes.
If several practices have problems with the same HMO, the medical association will attempt to set up a meeting with the plan to resolve these cases. "We might have an agenda of between 10 to 15 cases on the table we go through and try to resolve with the plan's medical director, provider relations representative, and other staffers," says Reiner.
Face-to-face meetings get results
Thus far, TMA claims a 75% to 80% success rate in resolving these negotiated settlements in the physicians' favor. "One thing I credit for our success rate is that the plan's people can't dodge you. We are face to face in the same room doing everything we can to make our physician member's case," says Reiner.
Another hard-ball tactic TMA is considering in its slow-payment campaign is hiring collection specialists to gather unpaid claims and capitation payments. "Businesses do this with consumers all the time. Why not an HMO?" says Reiner.
Lastly, TMA has found the threat of reporting long-overdue claims to a credit reporting agency sometimes loosens up long-held cash. "Like any other business, no plan wants any black marks on its credit report," notes Reiner.
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