Elusive Prompt Payment TDI charged to enforce current law

by Shellie Pruden, DCMS director of medical practice relations

After Gov Rick Perry vetoed HB1862, the prompt payment bill, he has directed Texas Department of Insurance Commissioner Jose Montemayor to increase enforcement of current law.

Commissioner Montemayor has committed to re-open the rules used to enforce prompt pay legislation passed in 1999. The agency has a big job trying to step up enforcement of a statute riddled with loopholes, and two years of contracts that circumvented penalties and ignored a standardized definition of clean claim. TDI will ask physicians and their operations experts to comment on the new rules. The commissioner’s goal is to implement rules that really work in a medical practice. To this end, he has appointed an ombudsman to assist physicians with claims payment issues. In addition, TDI has revamped its Web site to include a physician complaint form that populates a database for better tracking and trending, and conducted an insurance summit to announce a crackdown on those who delay payment.

Without legislative help, the next step in bringing relief to the financial crisis in physician practices will be difficult. A multipronged approach, including increased regulatory controls, better business practices, and involvement in the legislative cycle, will be necessary.

With the crackdown from regulators, physicians must improve their business practices to better manage insurance contracts, and to ensure accurate documentation, timely follow-up, and reporting of companies that use loopholes to not pay claims. Physicians will have to better manage insurance contracts and risk, terminating relationships with insurance companies that continue to not pay claims. Insurance companies have long played off physicians’ loyalty to the patient relationship; physicians have overlooked insurance’s business practices. But patient loyalty becomes increasingly overshadowed by pure economics. With decreasing reimbursement and increasing overhead, 60 percent of Texas physicians are having cash flow problems.

With TDI’s increased prompt payment oversight, health plans may increase requirements for accurate coding and documentation. This age-old battle of completing paperwork vs practicing medicine continues to gain momentum. Practice audits and physician and staff education are the easiest ways to stave off this potential problem.

As we approach the November election cycle, the key to long-term legislative effectiveness is to become involved in campaigns from the beginning. With redistricting, as many as 40 percent of the House and half the Senate seats will turn over. Members of the Texas Medical Association Political Action Committee will work to choose and elect candidates who support physicians’ viewpoints. To learn more about TEXPAC, contact Tracy Knight, DCMS director of public affairs, at 214-948-3622 or tracy@dallas-cms.org, or visit the TEXPAC Web site at www.texpac.org.

The battle of timely claims payment likely will be in front of the Texas Legislature in 2003, for the fourth consecutive session. In the best-case scenario, the Legislature will codify upcoming rules into statute that bring relief to the claims-payment problems. Worst case, physicians will continue to battle payment problems for 18 months until the issue can be taken before the Legislature again.