On June 8, 2010, I presented a detailed seminar, including questions and answers, to professional coders in Newton, NJ.  The issues, all relevant to managed care and related billing, included prompt payment, bundling, downcoding, no-fault, workers' compensation and so forth.  The powerpoint presentation used is attached.

Promp-Pay-Powerpoint.pdf (1.17 mb)

Slow claim payment is a major concern for physicians and other providers and results in a very damaging impact on practices. Under the New Jersey prompt payment laws, managed care organizations are required to reimburse physicians and dentists within set time frames. For noncapitated, fee for service fully insured claims, they must pay within 30 days after receiving an electronic claim and 40 days of one sent by regular mail. For capitated claims, the insurer must pay no later than 5 days of the due date set forth in the provider agreement. In addition, the insurer must contact a provider within those same time frames to request missing or incomplete claim information in order to process the claim. As of July 2006, the carrier must now request such information within 7 days when the claim is submitted electronically.

There are significant consequences to the carrier for non-compliance. If the insurer fails to pay or deny the claim or fails to request missing or incomplete information timely and by expeditious means, it waives the right to contest payment of that claim unless the claim was submitted fraudulently. In other words, if it turns out that the claim could have been properly denied because there was no coverage on the date of service, but the carrier did not tell the doctor that until after the statutory deadline, the claim must now be paid. Moreover, under the law, physicians are entitled to interest on all late paid claims. Prior to July 2006, companies were charged 10% annual interest. The rate is now 12%.

There are simple steps that you can take to help ensure the fastest possible turnaround on claims payment:

• Submit Electronically: The benefits include faster processing times, fewer errors and less missing information.
• Send “Clean Claims”: A “clean claim” is a complete claim containing all information requested on the claim form. Take the time to ensure that your HCFA-1500 forms or equivalent forms are filled out fully and accurately.
• Don’t Resubmit: Submit a claim only once. Duplicate submissions can backfire because HMOs often recognize them as the “only” claim and ignore the original- which delays payment to the doctor.
• Establish Policies: Set and follow internal procedures. Submit claims the same or next day after the service is provided. Use a practice management software package to build monthly reports to track and document all transactions, including all communications and telephone calls to the carrier to follow-up on outstanding claims.
• Involve Patients: Communicate with patients from the start. Inform them that their participation in the claim process might be necessary to provide the insurer with additional information. Prepare a written cooperation agreement with the patient.