The study is a follow-up to a prior publication of delayed paid claims that also appeared in the AJR. In the current work, the authors focused on unpaid claims, analyzing 48,217 claims submitted in February, June and October of 2000 to six major payers for 93 radiologists in New Jersey. The percentage of completely unpaid claims after the legal 40-day limit was 28%; after 170 days, the percentage was 6%. The study shows that lost revenue from unpaid claims was 28 times greater than the lost interest associated with delayed payments.
According to lead author on the study Lawrence C. Swayne, MD, of Morristown Memorial Hospital and Morris Imaging Associates in Morristown, NJ, the issue of prompt payment has become prominent in managed care reform. "Payment abuses have become so widespread that prompt payment laws have been enacted in 47 states. Despite these efforts, our study suggests that managed care companies may pocket close to $20 billion per year for unpaid claims at the expense of U.S. physicians," said Dr. Swayne.
And it is not just the physicians who are affected, according to Dr. Swayne. "Ultimately, the general public bears the final burden. Patients without insurance or with insufficient insurance experience decreased access. Even patients with insurance coverage frequently discover their choices are limited as physicians are forced to cease participating with a tardy payer," he said.
In addition, the study found a clean claims filing rate of 97% that, according to the researchers, contradicts the managed care organizations' assertion that about 50% of provider submitted claims are flawed. Furthermore, they said, the majority of late payment (88%) and nonpayment (68%) claims occurred without any notification, rather than as the result of a dispute. "Physicians contracting or engaging in a dialogue with managed care organizations seeking to impose additional 'quality metrics' coupled with vague promises to 'pay for performance' should be wary, given that payers are currently in violation of prompt payment laws for their own monetary gain," said Dr. Swayne.
"The study has a potential applicability to medicine as a whole, since radiology is a high-volume referral practice with a broad exposure to managed care and interaction with numerous primary care physicians, medical subspecialists and surgeons," said Dr. Swayne.
Journal
American Journal of Roentgenology