DCMS Comments to Commissioner José Montemayor

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July 30, 2003

Commissioner José Montemayor
Texas Department of Insurance
P.O. Box 149104
Austin, Texas 78714

Re: Comment Upon Proposed Rules Related to Submission of Clean Claims 21.2801-21.2809, 21.2811-21.2819, 21.2821-21.2825; Utilization Review Agents 19.1703, 19.1723, and 19.1724; and Physician and Provider Contracts and Arrangements 11.901; Preferred Provider Plans 3.3703.

Dear Commissioner Montemayor:

The Dallas County Medical Society would like to submit the following comments on the proposed rules for implementing Senate Bill 418. On behalf of our 5800 members, we thank you for your work in drafting these proposed rules. Our members are anxious to implement a law that is intended to bring tremendous relief to the slow pay/no pay tactics that continue to threaten the viability of medical practices.

The following are our comments regarding the proposed rules:

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UTILIZATION REVIEW AGENTS

§19.1703. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

(9) Declination – a response to a request for verification in which an HMO or preferred provider carrier declines to guarantee payment for proposed medical care or health care services prior to receiving a claim for the proposed services. A declination is not a determination that a claim resulting from the proposed services will not ultimately be paid.

Comment: We feel that TDI has misconstrued the intent of the verification process as a “guarantee of payment.” We ask that the definition be changed to more closely represent the statute:

(9) Declination — a response to a request for verification in which an HMO or preferred provider carrier declines to provide verification. Any declination will include the specific reason the verification was not provided.

Please note our additional comments on verification below.

(37) Verification – a guarantee by an HMO or preferred provider carrier that the HMO or preferred provider carrier will pay for proposed medical care or health care services if the services are rendered within the required timeframe to the patient for whom the services are proposed. The term includes pre-certification, certification, re-certification and any other term that would be a reliable representation by an HMO or preferred provider carrier to a physician or provider if the request for the pre-certification, certification, re-certification, or representation includes the requirements of §19.1724(c) of this title (relating to Verification).

Comment: The statute never mentions verification as a guarantee of payment; therefore, we strongly disagree with the TDI interpretation of the definition and the process supporting it. When we were consulted as the bill sponsors drafted this legislation, verification never was intended to be a guarantee. A material misrepresentation of the service needed, substantially failing to perform a service, and a timely filing deadline of 95 days were conditions set forth by the statute that preclude a verification from being a “guarantee.” We ask that TDI return to the definition of verification set forth in the statute:

(37) Verification – a reliable representation by an HMO or insurer to a physician or health care provider that the HMO or insurer will pay the physician or provider for proposed medical care or health care services if the physician or provider renders those services to the patient for whom the services are proposed. The term includes precertification, certification, recertification, and any other term that would be a reliable representation by an insurer to a physician or provider.

§19.1724. Verification

(c) Any request for verification shall contain the following information:
(1) patient name;
(2) patient ID number;
(3) patient address;
(4) patient date of birth;
(5) name of enrollee or subscriber;
(6) enrollee or subscriber ID number;
(7) enrollee or subscriber date of birth;
(8) patient relationship to enrollee or subscriber;
(9) initial diagnosis;
(10) procedure code(s);
(11) name and address of hospital or facility, if applicable;
(12) proposed date of service;
(13) name of employer, if applicable;
(14) group number, if applicable;
(15) name and contact information of any other carrier, if known, including the other carrier´s name, address and telephone number, name of enrollee, plan or ID number, group number (if applicable), and group name (if applicable);
(16) name of preferred provider providing the proposed services;
(17) preferred provider´s federal tax ID number; and
(18) place of service.

Comment: It is not unreasonable for a plan to disclose, prior to a service being delivered, a reliable representation that a service is covered. When a health plan designs a benefit plan with an employer, it does so based on covered services, not by diagnosis code and procedure code. Because this is the way a health plan represents the services to the employers when designing a benefit package, it is not unreasonable to communicate this information to a physician waiting to treat a patient. It should be adequate information for the physician to provide presenting symptoms to find out if a service is covered. This especially will be necessary as SB541 and SB10 are implemented, allowing employers to design benefit plans that exclude state-mandated services. We question why TDI is requiring enough information to pre-adjudicate a claim. It is impossible for a physician to know what CPT or procedure codes will be used to treat a patient before an examination. However, when patients schedule appointments, they disclose symptoms that could identify with enough specificity a reliable representation that the service is covered. We offer that the following information be requested in a verification process:

Patient name;
Patient ID number;
Patient date of birth;
Presenting symptoms;
Name of insured;
Proposed date(s) of service;
Name of provider(s)/provider ID; and
Place of service (office, ASC, hospital, etc.)

(e) If necessary to verify proposed medical care or health care services, an HMO or preferred provider carrier may, within three days of receipt of the request for verification, request information from the preferred provider in addition to the information provided in the request for verification. An HMO or preferred provider carrier may make only one request for additional information from the requesting preferred provider under this section.

Comment: Additional information should be conditional and asked for at the time the request for verification is made. Any exception is construed as a delay tactic by the insurance company and further will impede patient care. Please note our comments below on elements required to provide verification.

(1) Except as provided in paragraph (2) of this subsection, an HMO or preferred provider carrier shall provide a verification or declination in response to a request for verification without delay but not later than 15 days after the date of receipt of the request for verification.

Comment: The statute provides that the verification be provided “without delay.” We are gravely concerned that the interpretation of “without delay” has been defined by TDI as 15 days. In effect, patient care will be severely jeopardized. If patients have to wait 15 days from onset or initial appointment until a service can be delivered, not only will they have to schedule two appointments, it may seriously jeopardize their health. The intent of this legislation is to force the health plan to communicate the terms of its contract before a service is delivered. Providing 15 days for them to make the determination guts the intention of the process in addition to compromising patient care. This is a loophole that never was provided for in the legislation.

2) If the request is related to a concurrent hospitalization, post-stabilization care or a life-threatening condition, the response must be sent to the preferred provider without delay but not later than 72 hours after the HMO or preferred provider carrier received the request.

Comment: If a patient has a life-threatening condition, 72 hours is entirely unreasonable to find out if the service would be covered. “Without delay” is the standard set forth in statute and should be immediate.

h) A verification or declination may be delivered via telephone call or in writing. If the verification or declination is delivered via telephone call, the HMO or preferred provider carrier shall, within three calendar days of providing a verbal response, provide a written response which must include, at a minimum:

Comment: We believe TDI should not limit to telephone and writing the opportunity to communicate verifications. With the advancement of technology and Internet use, we ask that verifications be provided through any means that would expedite the process. Some health plans now use the web for this type of service, and it would be counterproductive to limit technological opportunities.

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SUBMISSION OF CLEAN CLAIMS

§21.2802. Definitions

(2) Billed charges -- The charges made by a physician or provider who renders or furnishes services, treatments, or supplies provided the charge is not in excess of the general level of charges made by other physicians or providers who render or furnish the same or similar services, treatments, or supplies to persons in the same geographical area [and] whose illness or injury is comparable in nature or severity. In the event of a case rate agreed to between the physician or provider and the HMO or preferred provider carrier, billed charges shall be considered the higher of the case rate or billed charges.

Comment: Our members have grave concerns that the TDI continues to interpret billed charges in a manner that is not supported by statute. Under the proposed (and current) definition, the health plan determines the “general level of charges” and thereby is able to set the fee schedule at less than the contracted rate, avoiding any penalty for late payment. We ask that TDI strictly enforce the definition determined in the statute as “billed charges as submitted on the claim.” Any alternative interpretation will bankrupt the intent of the legislation by allowing the health plan access to an unacceptable loophole. From claim history, disclosure of fee schedules at the time of contract negotiation, and other means, a physician's pattern of billed charges easily is ascertained. If abuses exist, the Medical Practice Act provides for action against physicians who have excessive billing practices. Health plans cannot be given carte blanche to determine billed charges to avoid penalty when claims are not paid timely or correctly.

§21.2803. Elements of a Clean Claim.

(3) if applicable, any coordination of benefits or non-duplication of benefits information pursuant to subsection (c) of this section.

Comment: In an effort to more clearly communicate the procedure, the statute uses the language “coordination of payment.” Benefits are a condition of a contract between a health plan and a covered entity, typically an employer. This statute governs only the relationship between a physician and a health plan. We ask that TDI respect this distinction and replace “coordination of benefits” with the more accurate language of “coordination of payment,” as specifically delineated in SB418.

1) Required [ Essential ] data elements for physicians or noninstitutional providers. The [ Unless otherwise agreed by contract, the ] data elements described in this paragraph are required [ necessary ] as indicated and must be completed in accordance with the special instructions applicable to the data element for clean claims filed by physicians and noninstitutional providers.

H) other insured's or enrollee's name (CMS 1500, field 9), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(P) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(I) other insured's or enrollee's policy/group number (CMS 1500, field 9a), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(P) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(J) other insured's or enrollee's date of birth (CMS 1500, field 9b), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(P) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(K) other insured's or enrollee's plan name (employer, school, etc.) (CMS 1500, field 9c), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(P) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element. If the field is required and the physician or provider is a facility based radiologist, pathologist or anesthesiologist with no direct patient contact, the physician or provider must either enter the information or enter NA (not available) if the information is unknown;

(L) other insured's or enrollee's HMO or insurer name (CMS 1500, field 9d), is required if patient is covered by more than one health benefit plan, generally in situations described in subsection (c) of this section. If the required data element specified in paragraph (1)(P) of this subsection, "disclosure of any other health benefit plans," is answered "yes," this element is required unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

Comment: In operationalizing these rules, the physician or provider must submit with the claim additional documentation that would prevent electronic filing of claims under the condition of coordination of payment. With the support of the new statute allowing for primary and secondary coverage information to be submitted at once, a medical practice has strong incentive to provide primary and secondary insurance coverage information. It should be assumed that the good faith, but unsuccessful, attempt to secure additional information was made.

(M) [ (H) ] whether patient's condition is related to employment, auto accident, or other accident ( CMS [ HCFA ] 1500, field 10) is required, but facility based radiologists, pathologists, or anesthesiologists shall enter "N" if the answer is "No" or if the information is not available ;
(S) [ (O) ] date of [ current illness ,] injury[ , or pregnancy ] (HCFA 1500, field 14) is required, if due to an accident ;

Comment: Although we appreciate the acknowledgement that hospital-based physicians may not have access to this information, the definition should be broadened to include consulting physicians and other physicians who provide services without having actual contact with the patient. Examples include, cardiologists interpreting electrocardiograms, neurologists interpreting encephalograms, and pulmonologists interpreting pulmonary function tests performed at locations other than their office or hospital. Consulting physicians do not have access to additional information that would allow them to complete out the claim any differently than do hospital-based physicians. We also would like to point out that radiologists and pathologists might be office-based; not hospital-based; for example, a radiologist who provides teleradiology services for rural communities. We understand that the carriers may be limited in their ability to identify all the providers who do not have direct patient contact, but the exception should be equitably applied to all those who meet it. Additionally, this exception should be applied to Fields 9 and 9a through 9d. According to the instructions for Subsection (b)(1)(P), [CMS 1500, Field 11d], Subsections (b)(1) (H)-(L) are required if the answer is “yes,” and, therefore, the same exceptions should apply to Fields 9, 9a, 9b and 9d.

(S) [ (O) ] date of [ current illness ,] injury[ , or pregnancy ] (HCFA 1500, field 14) is required, if due to an accident ;
[ (P) first date of previous same or similar illness (HCFA 1500, field 15); ]

Comment: TMGMA applauds the decision of the TDI to amend the requirements previously defined for these two fields. Because of their specificity and limited applicability, they have been corrected to be conditional. This action alone will have positive implications for our members’ practices.

Subsection (b)(1)(T) name of referring physician or other source (CMS1500, field 17) is required for primary care physicians, specialty physicians and hospitals, however, if there is no referral, the physician or provider shall enter "Self-referral" or "None";

Comment: We question the necessity of including this information when the exclusion of this information supports the assumption that there is no referring physician or the patient self-referred. Health plans never have required this information and formatting would be required to include this for claims submission.

Subsection (b)(1)(X) if the claim is a duplicate claim, a "D" is required, if the claim is a corrected claim, a "C" is required (CMS 1500, field 22)

Comment: We understand that the TDI Technical Advisory Committee on Claims Processing agreed that Field 10d Reserved for Local Use would be a better choice than field 22 for the identification of duplicate and corrected claims. We recommend that, rather than “D” for duplicate claim and “C” for corrected claim, the TDI consider adopting the same code scheme as required by the 837P Implementation Guide for data element 1325 Claim Frequency Type Code, Code Source 235. Physicians and providers will be implementing the Claim Frequency Type Codes as part of their HIPAA compliance activities, and this would provide consistency between electronic claims and nonelectronic claims. Code Source 235 is the same codes used in Field 4 of the UB-92 (See Subsection (b)(2)(C)). As with Field 4 of the UB-92, "7" would indicate the claim is a duplicate and "8" if the claim is a corrected claim (See 837P Implementation Guide Addenda, page 22, and 837P Implementation Guide Appendix C, page 5).

Additionally, we recommend the TDI provide direction when a physician contacts a carrier to check on the claim status of a nonelectronic claim. A carrier’s intake processes, may not always be able to determine that a specific non-electronic claim has been received. The physician is told that the carrier has no record of that claim and advises the physician to resubmit. Under that scenario, the physician should designate the claim as a corrected claim, even though modifications to the information on the claim may not have been made. This would ensure that the physician is not penalized for the inadequacy of the carrier’s intake processes for non-electronic claims.

(II) amount paid (CMS 1500, field 29), is required if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan in accordance with paragraph (1)(P) of this subsection and as required by subsection (c) of this section;

Comment: If the physician received primary payment, we support that this element be required. The statute allows for both primary and secondary to be filed simultaneously, and allows for communication between those plans to coordinate payment. No element or definition should prevent the streamlining of the coordination of payment or extend the 45-day time limit in which the plans are required coordinate and make payment to the physician.

[ (e) ] Coordination of benefits or non-duplication of benefits. If a claim is submitted for covered services or benefits in which coordination of benefits pursuant to §§3.3501 - 3.3511 of this title (relating to Group Coordination of Benefits) and §11.511(1) of this title (relating to Optional Provisions) is necessary, the amount paid as a covered claim by the primary plan is [ considered to be ] a required [ an essential ] element of a clean claim for purposes of the secondary plan's processing of the claim and CMS [ HCFA ] 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(II) [ (b) (3)(I) ] and (b)(2)(GG) [ (T) ] of this section. If a claim is submitted for covered services or benefits in which non-duplication of benefits pursuant to §3.3053 of this title (relating to Non-duplication of Benefits Provision) is an issue, the amounts paid as a covered claim by all other valid coverage is [ considered to be ] a required [ an essential ] element of a clean claim and CMS [ HCFA ] 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(II) [ (b) (3)(I) ] and (b)(2)(GG) [ (T)] of this section. If a claim is submitted for covered services or benefits and the policy contains a variable deductible provision as set forth in §3.3074(a)(4) of this title (relating to Minimum Standards for Major Medical Expense Coverage) the amount paid as a covered claim by all other health insurance coverages, except for amounts paid by individually underwritten and issued hospital confinement indemnity, specified disease, or limited benefit plans of coverage, is [ considered to be ] a required [ an essential ] element of a clean claim and CMS [ HCFA ] 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(II) [ (b) (3)(I) ] and (b)(2)(GG) [ (T) ] of this section. Notwithstanding these requirements, an HMO or preferred provider carrier may not require a physician or provider to investigate coordination of other health benefit plan coverage.

Comment: This rule deviates from the statute and should be changed to reflect its intent. We ask that the more accurate language of “coordination of payment” be used in this section as reflected in the statute. Coordination of payment is an insurer-to-insurer function. By placing the physician in the middle of the process, it extends the timeliness of payment. If both primary and secondary payors are reflected on the claims, and all other required information is included, health plans have enough information to communicate with each other in coordinating payment. The statute forces the streamlining of this process and the rules should reflect that.

e) If a physician or provider submits an electronic clean claim that requires coordination of benefits pursuant to §§3.3501-3.3511 of this title (relating to Group Coordination of Benefits) or §11.511(1) of this title (relating to Optional Provisions), the HMO or preferred provider carrier processing the claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider. The primary payor may submit primary payor information electronically to the secondary payor using the ASC X12N 837 format and in compliance with federal laws related to electronic healthcare claims, including applicable implementation guides, companion guides and trading partner agreements.

Comment: As stated in the above comment, the statute forces the streamlining of this process. We have concern that the rules provide that the primary payor “may” submit primary payor information. The statute provides for this process to be mandatory by using the word “shall,” and the language in the rule should reflect that requirement. Again, the language also should reflect the more accurate “coordination of payment” rather than “coordination of benefits,” as reflected in the statute. The rule should read: “The primary payor shall coordinate with the secondary payor and determine the appropriate payment for the submitted claim. The primary payor may submit primary payor information electronically to the secondary payor using the ADCX12N837 format and in compliance with federal laws related to electronic healthcare claims, including applicable implementation guides, companion guides and trading partner agreements.”

§21.2815. Failure to Meet the Statutory Claims Payment Period

(3) If the balance of the claim is paid on or after the 91st day after the end of the applicable 21, 30 or 45 day statutory claims payment period, pay to the preferred provider, in addition to the contracted amount owed, a penalty computed under paragraph (2) of this subsection plus 18% annual interest. Interest under this subsection accrues beginning on the date the HMO or preferred provider carrier was required to pay the claim and ending on the date the claim and the penalty are paid in full.

Comment: Although the statute supports an interest penalty that accrues from “the date the claim payment is due,” which we assert would be the 46th day, we believe the legislative intent is that interest will begin to accrue on the 91st day and will be based on the balance of the unpaid claim, including the final penalty amount that is applicable.

For example, if the outstanding contracted rate is $100 and the penalty under Subsection (2) is $10, the interest would be calculated based on $110 multiplied by the 18 percent interest rate for the length of time until the date the final payment is made. Thus the amount owed to a physician or provider sixty (60) days after the end of the 91st day, or the penalty period, would be: $100 + $10 + [($100+$10)*(18 percent * (60 days/360 days))] =$113.30 with $3.30 attributable to accrued interest.

§21.2816 . Date of [ Claim ] Receipt.

(1) submit the communication [ claim ] by United States mail, first class, by United States mail return receipt requested or by overnight delivery service, and maintain a log that complies with subsection (h) [ (f) ] of this section [ that identifies each claim included in the submission, include a copy of the log with the relevant submitted claim, fax or electronically submit a copy of the log to the HMO, preferred provider carrier or delegated claims processor on the date of the submission and maintain a copy of the fax transmission acknowledgment or proof of electronic submission ];

(h) [ (g) ] Any entity submitting a communication under this section may choose to maintain a mail log to provide proof of submission and establish date of receipt. The entity shall fax or electronically transmit a copy of the mail log, if used, to the receiving entity at the time of the submission of a communication and include another copy with the relevant communication. The log shall identify each separate claim, request for information or response included in a batch communication. The [ claims ] mail log [ maintained by physicians and providers ] shall include the following information: name of claimant; address of claimant; telephone number of claimant; claimant's federal tax identification number; name of addressee; name of HMO or preferred provider carrier; designated address, date of mailing or hand delivery; subscriber name; subscriber ID number; patient name; date(s) of service/occurrence, [ total charge, and ] delivery method , and claim number, if applicable .

[ (h) An example of a claims mail log that may be maintained by physicians and providers is as follows: ]
[Figure: 28 TAC §21.2816(h)]

FOR COPIES OF THE CLAIMS MAIL LOG, CONTACT Sylvia.Gutierrez@tdi.state.tx.us

Comment: The log is duplication of information already contained in the claim form. Because of the increase in resources needed to complete the log, we ask that TDI and the health plans be willing to accept any alternate document that contains the same information as required in the log. An example might be a “print screen” from the practice management system used by the practice. The accuracy and inclusion of the information would net the same result as completing a labor-intensive log. Our members understand from the proposed rule that the log is conditional but are concerned that TDI will refuse to enforce payment deadlines unless the labor-intensive log is maintained. In addition, faxing and mailing the log would be redundant. If a communication were provided when the claim is sent, it would not be necessary to include a fax transmission of the log to submit the claim.

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PREFERRED PROVIDER PLANS
and
PHYSICIAN & PROVIDER CONTRACTS & ARRANGEMENTS

3.3703(a)(21) an insurer may require a preferred provider to retain in the preferred provider's records updated information concerning a patient's other health benefits

11.901(11) an HMO may require a contracting physician or provider to retain in the contracting physician or provider's records updated information concerning a patient's other health plan benefit plan coverage.

Comment: The focus of a physician practice should be the delivery of healthcare. SB 418 is an indication that the Legislature agrees that physicians should focus on health care delivery and be free from the burdens that slow pay/no pay places upon practices. To that end a physician should be required only to collect health information -- not coverage information. That sort of information is available to health plans through direct communication with their enrollees. To that end 28 TAC 3.3703(a)(21) and 28 TAC 11.901(11) should be deleted because they allow health plans to mandate that physicians track their patients’ healthcare coverage.

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Thank you for the opportunity to provide comments on the proposed rules. We look forward to the successful implementation of this long needed legislation.

Sincerely,

Robert W. Haley, MD President

Presley M. Mock, MD Chairman, Socioeconomic Committee

cc:

Gene C. Jarmon, General Counsel and Chief Clerk Mail Code 113-2A Texas Department of Insurance P. O. Box 149104 Austin, Texas 78714-9104 (512) 475-2025 Fax Kimberly Stokes, Senior Associate Commissioner Life, Health and Licensing Program Mail Code 107-2A Texas Department of Insurance P.O. Box 149104 Austin, Texas 78714-9104 (512) 475-2025 Fax Senator Jane Nelson Attn: Steve Roddy Room 1E.3 P.O. Box 12068 Austin, TX 78711-2068 (512) 463-9889 Fax

Representative John Smithee Attn: Lynsey Patrick Room CAP 1W.11 P.O. Box 2910 Austin, TX 78768 (512) 476-7016 Fax Representative Craig Eiland Room EXT E2.204 P.O. Box 2910 Austin, TX 78768 (512) 463-5896 Fax Shellie Pruden Director of Medical Practice Relations Dallas County Medical Society shellie@dallas-cms.org (214) 946-5805 Fax

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