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OPA Fights for Prompt Payment of Insurance Claims

OPA Monitors Implementation & Enforcement of SB 4

OPA was an active member of the Coalition for Patient Access that fought aggressively for the enactment of SB 4, the Prompt Pay bill. Now that it has become law, we want to make sure the implementation and enforcement of the law are helpful to Ohio’s pharmacists. Ohio’s prompt pay law establishes strict time frames for the processing and payment of claims. The law requires third party payers of health care services to make payments to health care providers promptly, which is defined in the legislation as within 30 days after receipt of the claim. In addition, the law requires third-party payers to inform health care providers of routinely requested information, so that clean claims can be submitted more quickly and payments received on a more timely basis. Insurers must establish a claim status check system so that providers and beneficiaries can determine the status of a particular claim. Under the new law, insurers must pay 18 percent interest on claims not paid in a timely manner. They can also face fines of up to $100,000 for a first offense and $300,000 for three or more violations if there is a consistent pattern of late payments.

The Department of Insurance is now providing a Provider Complaint Form that can be accessed through its website at www.ins.state.oh.us. They also offer Prompt Pay links that will update you on the main points of the law including the various time frames for the payment of claims, which claims are covered by the law, and information on claims processing. The website will direct you to a Complaint Submission Instruction link that will insure the forms you submit are filled out correctly, which will help to streamline the provider complaint process and capture the data needed to enforce the prompt pay law. The Department of Insurance may not be able to investigate and resolve individual complaints, however the department monitors complaint activity and collects and analyzes other data to monitor claim-handling practices. This information can be used to determine a consistent pattern of late payment.

The Ohio prompt pay law does not apply to claims submitted pursuant to Medicaid, Medicare or Self-funded ERISA (Employee Retirement Income Security Act) plans. For Medicaid claims, please contact the Ohio Department of Jobs and Family Services (614.644.0140). For Medicare claims, please contact the Centers for Medicare and Medicaid Services (312.886.6432). For Self-funded ERISA claims, please contact the United States Department of Labor (1.866.444.3272).

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