Not Getting Paid on Time? Here's What to Do

If you are in a network provider of the managed care organization (MCO), check the provision in your contract specifying the time period in which you are to be paid. If the MCO is not meeting its obligation to pay you within that time frame, wait until the deadline has passed before proceeding to the next steps. If your contract does not stipulate the time frame in which you must be paid, check with your state insurance commissioner (see URL toward end of article) about your state's prompt-payment requirements.

You should also check your patient's status with the MCO. At each visit you should ask patients whether their insurance has changed and record any new information. Patients may have lost their job and their insurance between visits or may have aged into Medicare. Also, in cases where prior authorization was necessary, check to ensure that the process was carried out and done properly.

If you find that your patient's insurance changed without your having been notified, then the patient is responsible for payment. (It's important that patients are aware of this policy when they begin treatment. A signed notice verifying that the patient agrees to this and other office policies should be kept in the patient's file.)

If you establish that the patient's visit was covered by the MCO and your payment is late, then, with these facts in hand, go on to step 2.

The first call to place is to the MCO's claims department and, if necessary, request to speak to a supervisor. If you do not get a satisfactory answer or resolution, then call the MCO's provider service line. Many members are frustrated by the “service” available through this line. The waits may be lengthy, and the service representatives sometimes don't seem to understand the issues. If the representative is unable to provide you with the necessary information for resolving your payment issue, ask to be transferred to a supervisor, just as you may have done when you called the claims department. (Try to stay on the line, even if the wait for the transfer seems lengthy; otherwise, you'll wind up having to begin the process again.) If the representative refuses to let you speak with a supervisor, or if you speak with the supervisor and still run into a brick wall, go on to step 3.

Now is the time to create your paper trail. Document the basis for your complaint (that is, quote your contract and/or state law with regard to the the number of days in which claims are to be paid and note when the unpaid claim was filed). Describe your failed attempts to have the problem resolved through the claims department and the provider service line to show that you have followed the appropriate steps. Then take your complaint to the top. Send your documentation in a letter to the MCO's CEO and copy your state insurance commissioner. You can usually find the name of the MCO's executive on the company's Web site, and your state insurance commissioner's contact information can be found at<www.naic.org/state_web_map.htm>.

If you need help with any of these steps, contact APA's Managed Care Help Line at (800) 343-4671. You also might want to check with your district branch to find out if your colleagues are having similar problems with a particular MCO. ▪