President's Page December 2003

Robert W. Haley, MD

Prompt Pay Victory
Third time is a charm

Few Texas physicians would question the importance of organized medicine in the state. With 38,000 members—80% of physicians in Texas—TMA is the largest state medical society in the nation. And with 5900 members—approximately 80% of physicians in Dallas County—DCMS is the nation’s third largest county medical society.

This year’s nationally visible victory on medical liability reform and Proposition 12 spotlighted the need to constrain the hungry hoards of legal and business profiteers who feed on the medical marketplace to the detriment of patients and the healing art. But no issue validates organized medicine more vividly than the campaign for prompt payment of physicians by medical insurers.

In the two years preceding the 2001 biennial state legislative session, TMA waged an effective campaign to inform state legislators about the problem—how the standards of honest, prompt payment of obligations, the foundation of American business activity, were being systematically abused. A leader in the state effort was Shellie Pruden, DCMS director of medical practice relations. She thoroughly studied the issues, kept up with daily developments, and strongly influenced TMA’s unfolding legislative goals.

Near the end of the 2001 legislative session, both houses of the Legislature passed a strong prompt pay bill, and it looked as if medicine had defeated the insurance lobby. But like the Terminator in a Schwarzenegger movie, big insurance suddenly rose out of the mangled wreckage of its campaign to extract a shocking, unexpected late-hour veto by the governor—testament to the industry’s enormous economic influence over public policy in the state. The sting enraged Texas physicians, who fought back with TEXPAC’s ill-fated opposition to the incumbent in the 2002 gubernatorial election.

After the election, TMA reorganized its staff and began a campaign to repeat the prior legislative gains in the 2003 session in the form of Senate Bill 418, sponsored by medicine’s perennial champion Sen Jane Nelson (R-Flower Mound), and this time to wrest the governor’s support from the powerful economic clutches of big insurance. As the session progressed, TMA staff again, along with DCMS staffer Shellie Pruden, helped defeat amendment after amendment generated by the relentless Terminator. When the smoke cleared at the end of the 2003 session, for the second time Texas physicians had won a resounding victory. Our TMA effectively had communicated to legislators the practical implications of slow pay and no pay on the daily practice of medicine. And this time Governor Perry signed the legislation.

With the insurance lobby scattered, physicians celebrated in the apparent denouement while, unseen, the Terminator again took shape, this time stalking with glistening economic muscle the Texas Department of Insurance and Insurance Commissioner José Montemayor. When the proposed rules for implementing SB 418 came out, physicians were horrified to find that major provisions of the legislation had inexplicably been ignored and the rules formulated simply maintained the status quo ante.

Again TMA staff, led by Rich Johnson and Teresa Devine as well as our own Shellie Pruden, analyzed the proposed rules, targeted the offending sections, and led TMA’s forces in the climactic shootout scene. On Nov 3 Presley Mock, MD, chair of the DCMS Socioeconomics Committee, and I, as president, signed the detailed letter of comment to TDI, prepared by Ms Pruden, with suggested wording changes to each of the 20 offending sections. Unique in this fight was the image of state legislators, led by Senator Nelson, objecting to TDI’s failure to follow the clear intent of the Legislature.

The result was a revised set of TDI rules, true to the signed legislation, that goes into final effect this month. From now on, the criteria for a “clean” claim are greatly simplified, and companies no longer can deny payment for claims they previously approved. For physicians seeking preverification, insurers now must approve or deny verification of payment “without delay” in 5 days or fewer rather than the 15 or 30 days they wanted, and claims personnel must be more available for after-hours calls. Insurers’ repetitive requests for patient and treatment information now will be limited, the time physicians have to submit claims has been extended, the time insurers have to recover overpayments has been limited, and physicians now can appeal insurers’ overpayment claims and need not repay until the appeal is decided. Insurers now must pay electronic claims within 30 days and paper claims within 45 days, and graduated penalties, based on physicians’ billed charges, will make payment delinquencies very expensive for insurers.

The point of telling this story is to make clear why we physicians must increasingly organize within our medical societies to combat the potent interests—the Terminators—that keep rising up to destroy our noble profession for economic gain. The privateers are many; the bureaucratic battles, long and complex. It takes large, committed memberships to maintain dedicated staff like our DCMS and TMA fighters.

So, here on the threshold of a new year, with more battle clouds on the horizon, renew your membership and participation in DCMS and TMA, and talk with those few on your medical staff who have not joined. Our patients and our profession need us.

Copyright 1997-2003, Dallas County Medical Society.
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