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Insurance Carrier Payment Disputes: Prompt Payment of Medical Claims

Answers to Frequently Asked Questions

What is the New York Prompt Payment Law?
What is the New Jersey Prompt Payment Law?
What is a Clean Claim?

Insurance Carrier Payment Disputes: Prompt Payment of Medical Claims

If an insurance carrier has failed to pay, dispute or deny your practice’s medical claims within the state-mandated period of time (usually between 30-60 days after submission of a clean medical claim, depending on the state and the type of response), you may have enforceable rights and remedies against the insurance carrier under your State’s prompt payment laws.

Insurance carrier are notorious for “delaying” their responses to the submission of clean medical claims - whether by payment, dispute or denial – and for using well-crafted “stall tactics,” such as frivolously requesting additional supporting medical documentation, disputing the use of medically appropriate diagnosis and/or procedure codes and by repeatedly questioning (not denying) coverage altogether. While insurance carriers have every right to enforce the terms of coverage under a given beneficiary plans, an insurance carrier is obligated to do so in a manner consistent with the applicable provider agreement (if any) and the laws of the governing state.

Many times, insurance carriers will delay payment of certain claims for several months (or longer) and will then wrongfully attempt to “renegotiate” the payment amount or just “partially” pay the outstanding claims in exchange for the providers receipt of a lump sum payment on the outstanding claims. Overburdened providers often succumb to these wrongful delay tactics, even where providers have the right to receive payment of the “full” outstanding amount, plus the state-mandated interest. Often times, providers will receive payment of the full outstanding amount, plus interest, within weeks of properly challenging an insurance carriers wrongful delay tactics.

It is critical that providers understand their options and rights when faced with an insurance carrier payment dispute. If you are faced with an insurance carrier payment dispute, contact health law attorney Ilana Sable, Esq. at (800) 976-4904 to learn more about your legal rights and the options immediately available to you.

Additional Articles Regarding Insurance Carrier Payment Disputes

5 Things Any Health Care Provider Can Do Right Now to Ensure Prompt Payment of Its Medical Claims

Sample Letters

Prompt Payment Default Letter

Useful Links and Resources

State of New Jersey, Department of Banking and Insurance - Health Care Providers
State of New York, Department of Financial Services - Health Care Provider Rights

Franchise Lawyer Book on franchising a business

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Ilana Sable

by Ilana Sable
New York and New Jersey Health Law Attorney

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