Representative Judd Matheny and Senator Janice Bowling announced Thursday the filing of "The HMO Transparency In Claims Processing Act of 2017".
This legislation amends existing laws to ensure Health Maintenance Organizations involved in a TennCare line of business give caregivers clear guidance on patient claims status, promptly pay claims, and use state dollars wisely for the benefit of vulnerable Medicaid patients. The Bill supports current law by giving caregivers and others the option to appeal claim denials through existing processes or in an expedited, more transparent way, officials said.
Provisions of the Bill require HMOs to: (1) designate an informed contact for interaction on the front end of claims processing; (2) issue clear and timely responses to caregivers when claims are denied; (3) maintain an online portal for the filing of appeals and display claims status; and (4) establish procedures to ensure claims are not denied arbitrarily when patient conditions are unchanged or when claims are re-submitted at their request outside timely filing deadlines.
The Bill contains related provisions and penalties may be imposed on HMOs for non-compliance.
Representative Matheny and Senator Bowling said: "We have heard repeatedly from constituents about lengthy delays in HMO claims payment and nonpayment for vital medical services. Providers say they receive conflicting guidance from HMOs and hard to understand reasons for claims denial. Some hear nothing from HMOs for months and no payment for years despite efforts to submit and re-submit claims."
Rep. Matheny said, "At least one constituent of mine has not received payment on some claims for over 3 years on millions of dollars in services rendered to vulnerable children mostly in rural areas with chronic conditions. HMOs provide a vital service, but we are convinced more needs to be done to ensure access to quality care for our citizens".
Rep. Matheny and Senator Bowling concluded, "We strongly believe this legislation promotes the public good and helps ensure the provision of needed quality medical services to our citizens. A Public Hearing to discuss specific provisions will be noticed soon".