Managed Care Contract Negotiations
Jan 23

Four guidelines to obtain timely physician payment from ERISA plans

It’s important to write a convincing letter when you want to receive timely payment from ERISA plans. Your letter to the plan should

  • tell the plan that the claim is unpaid and overdue–and that you’re entitled to notice about it. Tell the plan that it has been more than 30 days since you filed the claim and that you want payment immediately. Also point out that you have either authorization to act as the member’s representative or an appropriate assignment of benefits and therefore the right to be notified of any decision directly. Include a copy of that authorization or assignment with your letter

  • refer to regulation. Tell the plan that you believe that the plan’s failure to pay may be in violation of the regulation. Be specific. Specifically reference the regulation and quote some of it in the letter. If you have additional ammunition, use it. For example, if the plan is also in violation of a deadline imposed by your plan contract, point that out. And some plans are subject to state prompt-pay law, even if they tell you that they’re not, says South Carolina attorney Lawrence Laddaga. “It depends on whether a plan is insured or self-funded,” he explains.

  • ask for–or demand–payment. Tell the plan that you want the claim decided and paid immediately

  • copy the member. “The member should be informed of the status of the claim,” says reimbursement specialist Tammy Tipton. “And if the member has more information than you do, this puts him on notice to share it with you.”

    Author’s note: This week’s tip was excerpted from HCPro’s monthly newsletter, Managed Care Contracting & Reimbursement Advisor. For more information, click here.

  • About Reed Tinsley, CPA

    As a top advisor to physicians, I help increase practice profits by delivering hands-on, expert medical accounting/tax support, practice counsel, and revenue-building strategies. Read more →