working with physicians to develop fi- nancial recovery strategies. “We’re not a law firm, so in some cases, instead of pursuing a legal recovery, a practice may find that as a result of our analysis it’s best to pursue an alternative recovery strategy, such as contract rene- gotiations,” Mr. Reynolds said. “We’ll guide them through that process, and if it doesn’t produce results the practice wants, we can proceed to arbitration.” Both nVenio and O’Hanlon, McCol- lom & Demerath work on a contingency fee basis and receive a percentage of the money the companies recoup for the practice. Physicians often are surprised by nVenio’s findings, Mr. Reynolds says. “I’ve been involved in prompt pay analysis for the past 10 years, and in that time, I’ve never examined a practice that doesn’t have prompt pay violations,” he said. For more information about nVenio, visit
www.nvenioanalytics.com. The software O’Hanlon, McCollom & Demerath uses examines the day the practice submitted each claim going back four years and compares it with the day the insurance company paid it. Mr. Demerath says the firm uses the prompt pay law to supplement a prac- tice’s collection procedures and ensures that when claims haven’t been paid in full and on time, physicians receive all statutory penalties, interest, and attor- neys’ fees the law allows.
After analyzing claims and calculat-
ing the amount insurance companies owe in prompt pay violations and un- derpayments, the firm either submits a demand letter to the insurance com- pany or begins the arbitration process. Mr. Demerath says arbitration is often beneficial because an independent third party determines how much the physi- cian should be awarded. Mr. Demerath said he could not ethically disclose the amount of money his firm has recouped for physicians but did say his clients find the analysis and recovery process to be financially worthwhile. More information on O’Hanlon, Mc- Collom & Demerath is available online,
www.promptpaytexas.com.
Prompt pay actions, resources TDI levied its last high-profile prompt pay action in 2007 against United- Healthcare. TDI fined United $4.4 mil- lion for failing to achieve 98-percent prompt pay compliance during the third quarter of 2006 and for neglecting to submit complete and accurate quarterly complaint logs for all of 2006 and the first quarter of 2007.
In addition to the fine, TDI ordered United to:
• Continue to file complaint logs with TDI for an additional two years;
• Appoint an employee responsible for legal and regulatory matters relative to United’s compliance with Texas in- surance laws; and
• Resubmit corrected complaint logs for 2006 and the first quarter of 2007.
Since 2001, TDI has fined United four times for the way it pays claims. United isn’t the only company to struggle with prompt pay, however. In 2008, TDI fined MEGA Life and Health Insurance $225,000, Mercy Health Plans of Mis- souri, Inc. $100,000, and Community
First Health Plans, Inc. and MedImpact Healthcare Systems, Inc. $200,000 for failing to pay clean claims in a timely manner. For a full list of TDI disciplinary ac- tions against insurance companies for prompt pay, silent PPO, and other vio- lations, visit the TDI website,
www.tdi
.texas.gov. Select TDI Enforcement Ac- tions to view disciplinary orders begin- ning in 2007.
TMA staff and members of the TMA Council on Socioeconomics meet regu- larly with representatives of health plans to discuss insurance matters affecting physicians statewide. Physicians and health care profession- als can submit compliance complaints on TDI’s website,
www.tdi.texas.gov/ hprovider/
index.html. Additional infor- mation is available on TDI’s Prompt Pay FAQs webpage,
www.tdi.texas.gov/hpro vider/
ppsb418faq.html. TMA’s Payment Advocacy Depart- ment can help physicians and office staff members deal with claims-payment problems through the Hassle Factor Log, which is free to TMA members. Physi- cians can get answers to questions about
TMA wins passage of prompt pay law
Thanks to TMA’s advocacy in 2003, state lawmakers passed legislation requiring insurers to pay claims promptly. The law gives insurers 30 days to pay clean electronic claims
and 45 days to pay clean paper claims. Failure to do so results in penalties calculated on the difference between a physician’s billed charges and the contracted rate. Penalties are 50 percent of the difference during the first 45
days after the payment deadline and 100 percent of the differ- ence for late payment 46 to 90 days after the deadline. Beyond 90 days of the deadline, insurers are liable for 18-percent annual interest on the unpaid claim. TDI can and has fined insurance companies that violate the prompt pay law.
August 2013 TEXAS MEDICINE 59
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