195.925 Medicare Advantage Plans and Delayed Claim Payments ue to System Issues
The Medical Society of the State of New York (MSSNY) will urge the Centers for Medicare and Medicaid Services (CMS) to create specific, concrete guidelines applicable to any Medicare Advantage Plan (MAP) which has a “transition” of its system, or update of its claims processing system that could harm physician practices financially.
Any such guidelines from the Centers for Medicare and Medicaid Services (CMS) will impose punitive penalties (including payment of interest on delayed claim payments, and additional corrective actions), when an insurer’s “transition” of its system, and/or update of its claims-processing system, has led to (A) significantly delayed claim payments beyond the 30 days required by most contracts with Medicare Advantage Plans (MAPs); (B) improper adjudication of previously paid claims; and/or (C) improper denials followed by overpayment recoveries
As part of CMS’s punitive penalties and corrective actions, The Centers for Medicare and Medicaid Services (CMS), will require that any Medicare Advantage Plan (MAP) which has modified its system or updated its claim processing system should establish special service units, dedicated to resolving disputes and paying properly whenever the MAP’s system changes have led to (A) significantly delayed claim payments; (B) improper adjudication of previously paid claims; and/or (C) improper denials and then subsequent overpayment recoveries. (HOD 2016-266)
