Timeliness of payment language ensures your enrollees and your organization receive Alliance discounts. In 2010, third-party administrators’ (TPAs) failure to comply with this contract language in our agreements with UW Hospital, UW Medical Foundation, and Chartwell Midwest Wisconsin resulted in $397,000 in lost discounts for Alliance members. We will continue to work with TPAs to stress the importance of adhering to these provisions, but we encourage you to speak to your TPA as well. Please read on for more information.
Services at UW Must be Paid for within 30 Days to Receive Alliance Discounts
Timeliness of payment language requires that payment for services at UW Hospital, UW Medical Foundation, and Chartwell Midwest Wisconsin must be received at the UW within 30 days of receipt of the claim by The Alliance.
If payment is not received within the required timeframe, the contract rate is void and the payer is responsible for 100 percent of billed charges. This means that your enrollees and your organization are not able to take advantage of our negotiated contract rate.
Ensuring Payment is Received within 30 Days
To ensure you have access to negotiated rates, The Alliance reprices claims received from providers within three days of receipt and passes them on to the TPA for payment. In 2010, we processed 99 percent of all claims within three business days, but our average turnaround far exceeds this contracted promise. Our average turnaround for UW claims was:
- Electronic (99.45% sent this way) – 0.00 days
- Paper – 1.69 days
- All claims – 0.10 day
“Clean claims” are defined as claims with all the proper fields completed with sufficient information for The Alliance to reprice the claim. This includes claims that may be delayed in the payment process because itemizations, questionnaires, medical records, subrogation, reinsurance, third-party liability, or other items are needed. All claims sent from The Alliance are “clean claims” under terms of our agreements. These claims must be paid by TPAs within 30 days, but many TPAs are failing to do so.
We have provided repeated education to TPAs about the 30-day time period to minimize the financial impact to members. We have notified them that it begins on the day The Alliance receives the claim for repricing and ends on the day the UW or its associated entities receive payment. Many continue to assume that the 30-day time period starts on the day the claim is received by the payer and end when the check is dated.
We provide TPAs with a weekly report of all impacted claims repriced to help them to manage their inventory and ensure claims are paid within the provisions of the agreement.
We have also informed TPAs if they are in doubt to pay the claim, since the timeliness of payment provision includes a guarantee of a timely refund, as long as the request occurs within 6 months of payment.
We recognize the role your organization plays in influencing your TPA’s compliance. We encourage you to speak with your TPA to ensure they are making these payments in the 30-day timeframe to help you take advantage of Alliance negotiated rates. For more information, you may direct them to this article. If you have questions, please contact Jesse Oberloh, 800.223.4139 x 6645.