Ama Policy

Delay in Payments Due to Disputes in Coordination of Benefits H-190.969

Prompt Payment Deadlines

Our AMA:

(1) urges state and federal agencies to exercise their authority over health plans to ensure that beneficiaries’ claims are promptly paid and that state and federal legislation that guarantees the timely resolution of disputes in coordination of benefits between health plans is actively enforced;

(2) includes the “birthday rule” as a last resort only after parents/guardians have been allowed a choice of insurer and have failed to choose, and the “employer first rule” in any and all future AMA model legislation and model medical service agreements that contain coordination of benefits information and/or guidance on timely payment of health insurances claims;

(3) urges state medical associations to advocate for the inclusion of the “employer first rule”, and “birthday rule” as a last resort only after parents/guardians have been allowed a choice of insurer and have failed to choose, in state insurance statutes as mechanisms for alleviating disputes in coordination of benefits;

(4) includes questions on payment timeliness in its Socioeconomic Monitoring System survey to collect information on the extent of the problem at the national level and to track the success of state legislation on payment delays;

(5) continues to encourage state medical associations to utilize the prompt payment provisions contained in the AMA Model Managed Care Medical Services Agreement and in AMA model state legislation;

(6) through its Advocacy Resource Center, continues to coordinate and implement the timely payment campaign, including the promotion of the payment delay survey instrument, to assess and communicate the scope of payment delays as well as ensure prompt payment of health insurance claims and interest accrual on late payments by all health plans, including those regulated by ERISA; and

(7) urges private sector health care accreditation organizations to (a) develop and utilize standards that incorporate summary statistics on claims processing performance, including claim payment timeliness, and (b) require accredited health plans to provide this information to patients, physicians, and other purchasers of health care services.

Policy Timeline

CMS Rep. 8, I-98 Reaffirmation I-04 Reaffirmed in lieu of Res. 729, A-13, Modified: Res. 701, A-23; Modified: Rep. A-23; Modified: Res. 701, A-23; Modified: Rep. , A-23