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Does Your State Have a Provider's Bill of Rights?

While Congress struggles with the Patient's Bill of Rights many state legislatures have already passed some version of what could be called the Providers Bill of Rights. This legislation contains, with some variation, assurance that assigned claims will be paid to the provider within a reasonable length of time. Prompt payment acts have been passed by the states of Virginia, Texas, Florida, New Jersey, New York, Tennessee, Louisiana, Colorado and Michigan. Others likely to act include Georgia, Oklahoma and Pennsylvania. In this article, the Tennessee and Virginia laws are specifically reviewed.

The following provisions typically are included:

• The health care provider shall be paid the benefits due under a policy to the extent of the assignment within 30 to 40 days from the time the insurance company has received a final bill.
• It is the duty of the insurance company to request information required for payment of such benefits 15 (TN) to 30 (VA) days after receiving a claim for benefits.
• If any portion of the claim is under dispute because of the nature, necessity or charges for the services, the insurer shall, within 30 days, pay the amount of the claim that is not in dispute. The payer should notify the provider, in writing, of the reason(s) for assigned claims will be paid to the dispute and the amount of the dispute. (TN)
• If the dispute is due to the need for verification of services rendered and cannot otherwise be resolved by the insurer and healthcare provider, then the insurer shall schedule an on-premise audit within 30 days of the notice. The payer shall pay the amount determined to be due within 30 days of the audit. (TN)
• In the case of extended confinement within a health care facility, the provider may submit bills to the insurer on 30-day intervals and the payer will pay these interim bills within 30 days of receipt of the claims. (TN)
• If any portion of an assigned claim remains unpaid 40 (VA) to 60 (TN) days after a claim is received, the assignee of the claim may add an interest charge to the unpaid portion of the claim. The accrual of such interest charge commences on the 31st day, at an interest rate not to exceed one percent per month for an annual effective rate of 12 percent per year. Virginia law specifies that interest on late payments is to be paid without demand.
• If the provider offers a prompt payment discount, it shall apply to any portion of the claim paid with the period specified in the prompt payment plan. Failure of an insurer to comply with the provisions of the section may be reported to the State Commissioner of Insurance. (TN)
• No retractions may be made on previously authorized services. (VA)
• Payers must give 30-day advance notice of retractions of previously paid claims. (VA)
• Contracts must include all provider-applicable reimbursement policies, including fee schedules. (VA)
• Changes or amendments to contracts will require a 90-day advance notice. (VA)

What does this mean to you and your practice? First, you need to scrutinize your payment patterns from your major payers to determine their compliance with this legislation. Finally, the tables are turned and you get to see if someone else is in compliance! Secondly, for those "Outliers" identify how you wish to pursue the interest penalty for late payment. When you receive the interest penalty, where should the interest is applied?

Is this a great source of revenue? Assuredly, not! Should this help improve turnaround on your major payers of claims? Absolutely! Your job is to establish a reliable method for monitoring the claims payment, thereby ensuring that your payers know your practice is looking at their payment timing. Failure to do so would render this legislation useless.

Contact your state Medical Society for a summary of the bills within your state. We included only the Tennessee and Virginia legislation, and many of these laws are similar. However, your practice should review your particular state's guidelines.