Forum - Questions & Answers

Dec 28th, 2022 - hkdiedrich

Cigna medicare advantage

Hello, I have a medical claim from 8/2021 that was paid and mailed to an incorrect address.  Cigna Medicare said they were doing a check trace on 4/4/22 and to allow 180 days.  I have called several times since then and they say the case is still open and to "allow more time".  It has been over 8 months.  I tried calling Cigna credentialling and got no where.  Does anyone know who regulates medicare advantage plans in Texas?  Any help would be appreciated.  Thank you for your help.

Jan 3rd, 2023 - ChrisW   256  1 

re: Cigna medicare advantage

We understand a provider may be subject to fines for overpayments by a payer and must return any overpayments promptly. There is a Prompt Pay law that protects the provider as well.  This is the other side of the coin; insurance companies are responsible for prompt payment to providers for the service rendered to their insured. If a claim is not paid on time, most states require interest to be paid to the provider, which can be as high as 18%.

According to the Texas Department of Insurance, Prompt Pay FAQs, "If the provider believes the company has not paid a clean claim in compliance with 28 TAC §21.2807, the provider should contact the company and assert rights to penalty payments. If a provider feels they are owed a penalty payment after contacting the company, they should file a complaint with TDI."  

There are a few steps to take before filing a complaint under the Prompt Pay Law; you need to do your due diligence, such as follow up and follow up again.

If the address was incorrect on your check, that is a huge red flag. Make sure the provider's demographics are correct with the payer and verify all addresses under the provider's NPI, Tax ID, and Taxonomy, as well as group and individual past and present information. Verify the information the claim was processed under on their side.

The check may have been cashed by another provider; if you have multiple providers check there first.  If it was cashed, get a copy of the cleared check and the bank it was deposited to, and double-check your deposit history. 

If you still cannot locate it, utilize your claims representative and let them know you are looking at the Texas prompt pay timeframe. A provider rep is representing the payer acting as your advocate. Escalate the call until you get results. Be sure your next conversation when contacting the payer includes your state's prompt pay time frame, proof of a clean claim, and date of transmission.  Hopefully, you have kept good records regarding your communication. 

This is not intended to be advice to report your payers to the state but a guide on how to be prepared and educated on what documents are required when filing complaints with TDI if the need arises. 

If you do find you need to file a complaint for a payer that is habitually late in sending payment, be sure to include the following regarding a delay in claim payment:



  • A copy of the patient's health insurance ID card.

  • A copy of the claim submitted to the company for each patient and date of service.


Evidence of claim submission in the form of:



  • Electronic transmission confirmation,

  • Certified mail return receipt, or

  • Courier delivery confirmation.


Evidence of your collection activities for each claim prior to contacting TDI.


That evidence should be in the form of:



  • Documentation of phone conversations made to the health carrier.

  • Copies of correspondence mailed to the health carrier.

  • Replies you have received from the health carrier.


Be sure to check all of Texas' prompt pay laws; for example, according to the Texas Department of Insurance, "The 95-day claim filing deadlines of Texas Insurance Code §1301.102(a) and §843.337 apply to all physicians and providers who submit claims to a Managed Care Carrier (MCC), regardless of the physician's or provider's contracting status. Since these statutes apply only to a physician or provider who is licensed in this state, an out-of-state physician or provider is not subject to the 95-day claim filing deadline. Claims filed for services rendered to persons who are not covered under a MCC plan are subject to the claim filing deadlines in Chapter 146, Title 6, Civil Practices and Remedies Code. TDI and the stakeholder associations are making extensive educational efforts to inform all physicians and providers of the requirements of this law."Short of a payer experiencing a catastrophic event, even electronic claims are subject to the 30-day prompt pay timeframe.


Once you have exhausted all your possible options, you can contact the department of insurance by email at PromptPay@tdi.texas.gov or call them at 800-252-3439 to see the next steps you need to take.

This article is by no means to be used as a substitute for legal advice, and I would encourage you to reach out to your state department of insurance for your specific situation; in addition, it is not to advise to turn payers into the state. This is informational only to help you understand your rights.


Resource:
Texas Department of Insurance website
FAQs     
Prompt Pay Guidelines



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