CLAIMS DENIALS: Mid-Atlantic Providers Vs. HMOs
Under the headline "Medicine's Growing Battle: Getting Health Plans to Pay," today's Washington Post looks at "the latest struggle that hospitals and doctors in the mid-Atlantic region say they are facing in their long-running battle with health maintenance organizations and other health plans." According to hospital executives in Virginia and Maryland, health plans are "[i]ncreasingly ... delaying and denying payment for care that has already been delivered." Providers "say payment denials and delays have intensified as health plans struggle to improve their profitability." According to Maryland Hospital Association spokesperson Nancy Fiedler, the "frustration is so widespread" among Maryland hospitals that all of the state's acute care hospitals "have agreed that they will participate in a coordinated appeal to the (state) insurance administration." The association notes that the "volume of unpaid bills at Maryland hospitals increased 17.9% from the third quarter of 1995 to the third quarter of 1997 ... from an average of 60.8 days of claims receivable to an average of 71.7 days."
Other Side Of The Coin
Insurers, "for their part, say they are becoming more adept at spotting inappropriate bills." Mid Atlantic Medical Services Inc., corporate parent of the Optimum Choice health plan, "has even boasted to Wall Street of its success in finding reasons to invalidate medical claims it already has paid." In a recent talk with stock analysts, MAMSI CFO Robert Foss said, "Probably the brightest spot in our operations is the improvement in our claims-auditing capability. We have identified and taken advantage of significant opportunities to reduce current and future medical expenses by more closely challenging the contractual and medical appropriateness of claims received." The Post article also explores whether claims denials and delays violate certain state laws mandating coverage for emergency care and other services (Hilzenrath, 3/11).