by Mary Nava, Bexar County Medical Society Director of Public Affairs
The 80th Texas
Legislative Session
has wrapped up and
during the interim
we’ll be meeting
with our elected
officials on an individual basis to continue
discussions on health and medicine issues.
On occasion, we are invited to provide testimony
in committee hearings. As such,
we’ll also meet with our local members of
Congress to further medicine’s efforts at
the federal level.
Stay tuned for meeting updates and
highlights in the coming months. For more
information, please call Mary Nava at
301-4395.
On August 1, 2007, David Henkes,
MD was asked to testify before
the Congressional House
Subcommittee on Regulations, Health
Care and Trade on federal prompt pay
legislation.
The subcommittee is chaired by
Charlie Gonzalez (D-TX-20). In opening
remarks, Chairman Gonzalez said, “When medical offices do not receive
payment in a timely manner, it affects
their ability to provide the best care to
patients.” In addition, he said, “When
health providers feel that their practices
are threatened because of delays
in payment, there is a problem with
the system. We must ensure that these
small businesses are able to continue
to serve the communities that depend
on them.”
Also testifying at the committee
hearing were Cecil Wilson, MD on behalf of the American Medical
Association, Robert Merrill, DDS, MS
on behalf of the American Association
of Orthodontists, Gordon Austin,
DMD, PC on behalf of the Northwest
District of the Georgia Dental
Association and Frank Kelly, MD on
behalf of the American Academy of
Orthopedic Surgeons.
Although almost every state has
some form of law regarding the “prompt payment” of claims to physicians
for services rendered, all the witnesses
spoke in favor of additional federal
legislation regarding the problem.
They felt more comprehensive federal
legislation is necessary since larger
companies have self-funded health
care plans that are regulated by ERISA,
which trumps state laws.
In addition, there are many ways the
state legislative efforts have been
thwarted by technicalities. One technicality
spoken of is the submission of a “clean claim,” only to be told that
additional information is needed
sometimes several times before a claim
is ultimately paid.
Dr. Henkes spoke to the committee
about claims denied for covered
services. In his testimony, he recommended:
• The Committee mandate state regulation
of ERISA plan activity in a manner
similar to the state’s current
prompt pay statutes.
• Insurance companies must clearly
state whether disputed services are “covered” or “not covered.”
• If a service is covered, mandate that
there must be a payment for the
service.
• Insurance companies should not be
allowed to increase payment for one
service to cover a lesser payment for
another unless specifically agreed to
otherwise by both parties in a written
contract. The payment for each covered
service should be on an item for
item basis.
• Payment to someone other than the
provider, or a person authorized by
the provider for reassignment,
should be prohibited.
• The subcommittee should consider
a single set of rules on claims processing
by all insurance companies
that is clinically based so there is
transparency in the claims processing
system.
• In cases of dispute requiring arbitration,
the insurance company should
pay the majority of the arbitration
costs.
• Contracts should not have provisions
deterring class action arbitration or
litigation.
• The House Subcommittee on Regulations,
Health Care and Trade is a
part of the House Small Business
Committee that is chaired by Representative
Nydia Velazquez (D-NY).
