Insurers not paying? Fight back

April 8, 2005

More and more, doctors are refusing to let payers work the float at their expense.

But Houston attorney T. Daniel Hollaway says that's beginning to change. "More and more doctors are bringing lawsuits to get paid on time," he says. "Doctors are more willing to act aggressively than they were 10 years ago." Healthcare attorney Neil Caesar in Greenville, SC, agrees. "Doctors are beginning to stand up for their rights."

They're being helped by legislation. All states but two-Nebraska and South Carolina-now have prompt-pay statutes that give insurers deadlines for paying clean claims. If they miss the deadline, they're subject to interest and possible financial penalties. (Contact your state medical society to see what actions the law in your state allows.)

Complain,complain, complain Practice management consultant Karen Zupko in Chicago advises doctors to regularly check their accounts receivable and identify payers with outstanding claims. "If you've got unpaid claims past your state's time limit, get on them," she says. And if you belong to an IPA, "light a fire under it," she adds. "It should be on top of this."

If the insurer tells you it has no record of receiving your claim, resend it along with a letter stating that payment is overdue and spelling out the financial penalty provided for in your state's prompt-payment law.

Another insurer ploy: telling you that the claim you sent wasn't "clean." A clean claim is one that's properly submitted on either a UB-92 or CMS-1500 form and for which there's no dispute over medical necessity. If a claim isn't clean, an insurer can enter into a "good faith" dispute over the claims. It can nitpick them, saying that the codes are wrong or that the procedures are duplicative and unnecessary. Until the disputes are resolved, the company is under no obligation to pay.

Of course, the insurer could be right, and your claim might be to blame. So before taking your complaint any further, it's imperative to make sure that your claims are clean.

If you've been submitting clean claims, and your complaints to the insurer have gone nowhere, the next step is to complain to your state's insurance commissioner. (You'll find complaint forms at your state's department of insurance Web site. To find your state's site, go to the National Association of Insurance Commissioners Web site, http://www.naic.org, and click on "State Insurance Web Sites.") Make sure that you've kept good records on conversations you've had with payers about late claims. Always document the date of the conversation, the name of the person you spoke to, and what you discussed.