ERISA Script – Untimely Payment

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  • What date was the claim initially billed?
  • Was there any written communication (request for information, denial, underpayment) from the payor? IF SO, WHEN; HOW LONG AFTER THE CLAIM WAS BILLED?
  • How many days is the plan in violation of the above prompt pay statute?
  • Did they underpay the claim LATE, without the required statutory interest?
  • Are we contracted with the plan? IF SO, WHAT IS THE EXPECTED REIMBURSEMENT?

The staff will be tactful and professional in communicating with the payer when making this firm call and request immediate compliance to the applicable code section:

Hi, my name is ____________________, this call may be recorded for compliance purposes, I’m calling to investigate a possible violation of 29 CFR §2560.503-1(f)(2)(iii)(B) can I give you a patient ID#?

This claim was billed on {BILL DATE} and is now {DAYS LATE} in violation of the statutory timeframes for prompt processing. At this point, any contractual discounts have been forfeited and I have been asked to file a formal complaint with U.S. Department of Labor (D.O.L.) for full billed charges.  I am calling to help {PLAN NAME} prevent any unnecessary regulatory action by adjudicating this claim today.

Are you authorized to cut a check today to bring your plan back into compliance?

1. As you know, federal law requires {PAYOR} to pay claim under 29 CFR §2560.503-1(f)(2)(iii)(B), which states:

(B) Post-service claims. In the case of a post-service claim, the plan administrator shall notify the claimant, in accordance with paragraph (g) of this section, of the plan’s adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of the claim. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. (Emphasis added.)

I need to read you the following disclaimer: Your failure to reimburse {FACILITY NAME} is a serious matter and violates patient rights and health and safety codes designed to benefit the public (UNTIMELY PAYMENT HAS A NEGATIVE EFFECT ON LEVEL OF CARE).

The provision of continuous quality health care in our region depends on {FACILITY NAME} receiving payment for medically necessary services provided to patients.

Failure to comply with this telephonic notification of non-compliance to the applicable code section may result in a request for audit, investigation and the assessment of penalties by DOL.