Managed Care


1. If a physician applies for participation in a managed care plan, can the plan exclude him?

Yes. New York State is not what is known as an "any willing provider" state. This means that health plans are not legally obligated to accept every physician into their managed care networks. They can generally exclude them from participation for any reason or no reason at all.

2. Where a health plan has pre-authorized a physician to provide services, can it retrospectively go back and recoup such payment from the physician on the basis that the Enrollee was not covered under the plan when the services were rendered?

A health plan may not deny a claim for services that were preauthorized on the basis that the Enrollee's coverage was retroactively terminated more than 120 days after the health care services have been rendered, provided the physician submitted the claim within 90 days after the date the physician provided health care services.

3. Can a health plan "pend" payment on a claim because the Enrollee has not completed an Enrollee questionnaire for coordination of benefits?

A health plan is prohibited by law from denying payment on a claim, in whole or in part, on the basis that it is coordinating benefits with other potentially liable payers, unless the health plan has a "reasonable basis to believe that the insured has other health insurance coverage which is primary for that benefit." Where the insurer does have such a reasonable belief, it has only 45 days to request and receive such information. If no information is received at the end of 45 days, the claim must be adjudicated.

4. What can my practice do when one of our largest health plans continually fails to make timely payment on our claims?

By law, a health plan must make payment on "clean" claims which have been electronically submitted within 30 days of submission. Interest begins to accrue after 30 days. That being said, many health plans nonetheless "string providers along" and delay paying within this 30 day period. Providers may file complaints against such insurers with the New York State Department of Insurance under the New York Prompt Payment Law. Additionally, providers can directly seek recourse against such health plans under the terms of their Participating Provider Contract.