SMCMA Non Payment Action Plan: San Mateo IPA
1. If you have not already done so, send a formal written demand for payment to San Mateo IPA (See Sample Letter #1. State law (Health and Safety Code §1371) requires IPAs and Medical Groups to reimburse uncontested claims within 45 working days. Physicians are entitled to 10% interest per year on late payments beginning the first calendar day period.
2. Send unpaid claims to the appropriate health plans (Cigna, Blue Shield, Blue Cross etc) accompanied by a formal demand for payment (See Sample Letter #2. State law (Health and Safety Code § 1371) states that health plans are ultimately responsible for payment even when they subcontract with IPAs and Medical Groups). Send copies of the health plan letters to:
3. If you have outstanding Senior Claims, itemize them separately and include a statement in your letters to the IPA and to the health plans, that these are outstanding senior claims. As a condition of contracting with the health plans, HCFA requires that plans pay 95% of clean claim within 60 days for contracted doctors and 30 days for non-contracted doctors. Send a copy of your letters to:HCFA Region IXDivision of Health Plans and Providers 75 Hawthorne Street, Suite 401San Francisco, CA 94105
4. Complete the CMA Request for Information Regarding Unpaid Claims and fax it to 415-882-3390. This information is helpful to us in our advocacy efforts as we address the growing problems with non payment of claims. This also allows us to identify doctors who have been impacted by non payment so that we can notify you regarding information we obtain and actions that we may take on your behalf.
5. If you are considering contract cancellation, be sure to follow the terms for cancellation as written in your contract. For more information on contract cancellation see CMA On-Call 1055. Please be aware that if the group has filed bankruptcy, federal bankruptcy law prohibits termination of the contract due the bankruptcy. For more information on your rights and obligations in a bankruptcy, see CMA On-Call #0106. For more information regarding your obligations to provide care to patients, see CMA On-Call #0805.
6. How to protect yourself in the future.
Ø Become informed regarding the laws that protect you.
Ø Be sure that contract terms are consistent with the law (CMA Model Managed Care Contract; CMA On-Call #1069)
Ø Try to do some pre-contracting due diligence and background checks (See attached article "Stiffed: Protecting Yourself from HMOs and IPAs that Don't Pay". )
Ø Monitor your payments carefully and look for the warning signs of possible insolvency: late payment, payor claims they have not received your claims, sudden changes in contract terms, who else is not getting paid?
Ø Contact SMCMA and/or CMA for information if you are concerned about the financial solvency of a payor.
For more information: Visit SMCMA's web site at smcma.org, or visit the CMA web site at cmanet.org , "Select a Topic," select: "Reimbursement Advocacy." Scroll down to "CMA Assistance for Physician's Impacted by Medical Group/IPA Insolvency.". Call the CMA Reimbursement Hot Line at 888-401-5911.
Sample Letter #1 Demanding Payment of Claim With Interest
(Brackets [ ] indicate optional language or language which must be filled in by the physician)
Dear [Plan Administration; IPA or other contracting entity or DHS]:
We have not yet received payment for services provided to [Patient] on [Date of Service] in the amount of [Claim Amount]. The claim was sent to [Name of Plan/IPA or other contracting entity] on [Date Claim Sent]. Under California law, health care service plans (and their contracting entities) are required to pay non-contested claims within 45 days, and other third-party payors (and their contracting entities) within 30 days. If the claim is contested or denied, the plan must provide such written notice within the 30 or 45-day period. (Contested claims must be paid within the same time periods, after further required information has been sent.) [Under California law, DHS must make payment for claims by a small business or nonprofit organization within 30 days after a claim is received, unless reasonable cause for nonpayment exists.]
Otherwise, interest accrues on late claims at 10% (see Health & Safety Code §1371; Insurance Code §10123.13) (0.25% per day; see Government Code §927.6). To date we have not received notice that this claim is being contested.
We are writing this letter to demand payment of the above-referenced claim in the amount of [Claim Amount] plus 10% interest (0.25% per day). If we do not receive payment in this amount by [Date], we will consider legal action. Thank you in advance for your anticipated cooperation.
Sincerely,
[Name of Physician]
cc: California Medical Association
Sample Letter #2 to Patient Indicating Physician Termination
Dear [Patient]:
This letter is to inform you that as of [date], I will no longer be a member of [Name of Plan]. This does not necessarily mean that you will lose me as your physician. I am also a member of the following plans:
[List Plans]
You may discuss with your employer the possibility of your signing on with one of these other plans in order to continue to see me. Or, you may continue to see me on a private/full pay basis, although I understand that this may not, realistically, be an option.
Your other option is to continue your health care through [Plan Name] and [Plan Name] will see to it that you are transferred to another physician.
Please let me, your employer and [Plan] know, at your earliest convenience, which of the options, outlined above, is best for you. I have enjoyed serving as your physician.
Sincerely,
[Dr. ______________________]
cc: Plan Administrator
Click here for a list of California Health Plans
