Cleaning up Clean Claims DCMS and TMA want to help

by Shellie Pruden, DCMS director of medical practice relations

The Texas Legislature is considering a proposed bill to clean up the clean claims issues created out of the interpretations of House Bill 610--better known as the prompt payment or clean claim law. Helping get the clean-up bill passed could be the most important action physicians can take for the future of their practices.

Through the statute and rule-making process, a number of loopholes were developed allowing payers to circumvent the spirit of HB 610. When physicians review their accounts receivable, they are finding that not all claims are being paid in 45 days, as required by the legislation that went into effect in September. Instead, they have a stack of amendments to contracts that circumvent any relief or penalties the law provides. These amendments have complicated the claims payment process with additional documentation and data being required on the HCFA 1500.

In an effort to clean up the clean claim law, the TMA Council on Legislation has asked physicians to look at their accounts receivable and to tell legislators, Texas Department of Insurance, and TMA what went wrong. As a result, new legislation has been proposed. Robert T. Gunby Jr, MD, chair of the DCMS Legislative Affairs Committee, says physician support is crucial.

"Physicians will have to reveal the way some managed care companies have ignored the law or eliminated, through contracts, the penalties that would have served as a deterrent for not paying claims in 45 days," he says.

Let DCMS know about examples of any extraordinary measures managed care companies are requiring to constitute a clean claim and any correspondence over the last year requesting assistance or filing complaints with TDI on claims payment issues.

If legislators have no knowledge of the contracting loopholes and widespread misuse of the law, they have no motivation to change the statute.

"This is medicine's opportunity to fix the statute to get relief for doctors who suffer under abusive reimbursement practices," says Connie Barron, TMA associate director of legislative affairs. "It will take a lot of work to get it passed."

If you are interested in educating legislators about the importance of this proposed law, contact DCMS. DCMS can assist you if you would like to go to Austin to meet with a legislator or his healthcare staff. Contact Tracy Knight, DCMS director of public affairs, at 214-948-3622 or tracy@dallas-cms.org. You can find the contact information for your legislator on the Web site www.capitol.state.tx.us or call the voter registration office at 214-637-7937.

Audit your claims

Pull at least two claims that have not been paid in 45 days. After removing patient-identifying information, copy the claim, attach a cover letter with the information below, and send to:

Jose Montemayor
Commissioner
Texas Dept. of Insurance
P.O. Box 149104
Austin, TX 78714-9104

• Identify insurance company.
• Include dollar amount.
• Reason for nonpayment.
• Follow-up action taken.
• Staff resources spent in trying to get paid.

Please copy correspondence to:
Shellie Pruden
Dallas County Medical Society
P.O. Box 4680
Dallas, TX 75208-0680

The Honorable David Sibley
Texas Senate
Business and Commerce Chairman
P.O. Box 12068
Austin, TX 78711-2068

The Honorable John Smithee
Texas House of Representatives
Insurance Committee Chairman
P.O. Box 2910
Austin, TX 78768-2910