A few HMOs and PPOs have such a large customer base that they wield a lot of influence in the industry. A service provider that is habitually not being paid on time for services rendered even with a clean claim may be reluctant to complain for fear of losing the contract as retaliation.
One of the biggest hindrances to the effectiveness of the Texas Prompt Pay Act is this reluctance by service providers to expose this practice, and so it becomes vicious cycle. According to the website of prompt pay law firm Williams Kherker, the medical community is unable to provide adequate health services to the public because they are not being paid according to their contract in a timely manner for their hard work.
The solution is at hand, and retaliation should not be a concern. The Texas Insurance Code (§1301.066 and §843.281) and the Texas Administrative Code (§11.901(a)(2) and (8)) address the legal protection of service providers that file prompt pay violations from retaliation from insurance companies.
HMOs are forbidden by Texas Ins Code §1301.066 and §843.281 from cancelling, terminating, or refusing to renew service contracts of medical providers and health service providers for filing formal complaints against or appealing decisions of the HMO.
The Texas Administrative Code, on the other hand, requires that service provider contracts include anti-retaliation and prompt pay provisions. This gives the service provider legal protection and encourages them to report any illegal or unfair practices of the carrier, including delayed payments for clean claims.
Of course, some insurance companies will attempt to exert their influence by retaliating anyway on service providers that complain, confident that they have the legal muscle to do so. The laws say otherwise, and with the help of an experienced and competent prompt pay lawyer, these insurance carriers will find out they made a bad mistake.Read More